Laser laparoscopy in the treatment of endometriosis. A 5-year study

Minimally invasive surgery for ovarian endometriosis as a mean of improving fertility: Cystectomy vs. CO2 fiber laser ablation what do we know so far?

Minimally invasive surgery emerged in the 1980s as a safe and effective technique which requires smaller incisions and, usually, a shorter hospital stay compared to traditional surgery. Since then, minimally invasive surgery has expanded in many surgical specialties. One of its newest application in gynecology stands in the infertility management of young women with unexplained infertility or suspected endometriosis. In these cases, laparoscopy allows to diagnose and treat the disease aiming to increase at best the chances of spontaneous pregnancy or trough assisted reproductive technology. Nowadays, minimally invasive surgical approach of ovarian endometriosis consists of either laparoscopic cystectomy or ablative techniques such as laparoscopic CO2 fiber laser vaporization. Although cystectomy represents the gold standard according to the latest Cochrane review, some endometriosis experts are worried about its detrimental effect on healthy ovarian parenchyma and suggest preferring a less aggressive approach such as CO2 fiber laser vaporization. The aim of this review is to give an overview of the available evidences about the impact of the two surgical procedures on ovarian reserve markers and pregnancy outcome.

Medical treatment of ureteral obstruction associated with ovarian remnants and/or endometriosis: report of three cases and review of the literature

STUDY OBJECTIVE

Experience with low-dose intermittent danazol or prolonged gonadotropin-releasing hormone agonist (GnRH-a) with and without add-back therapy in endometriosis-associated ureteral obstruction.

DESIGN

Retrospective case series (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospital.

PATIENTS

Three women with endometriosis-associated ureteral obstruction.

INTERVENTION

The regimen of GnRH-a alone or with add-back included (1) leuprolide acetate 3.75 mg intramuscularly monthly; (2) micronized 17α-estradiol 1 mg/day by mouth; (3) pulsed norethinedrone 0.35 mg/day by mouth, 2 days on and/or 2 days off; and (4) letrozole 2.5 mg by mouth for the first 5 days of the first GnRH-a injection. Danazol, 100 mg/day by mouth, was prescribed as a regimen of 3 months on, 3 months off, for 4 years.

MEASUREMENTS AND MAIN RESULTS

The first case was a 50-year-old woman, gravida 3, para 3, body mass index (BMI) 27 kg/m(2), with multiple surgeries, including hysterectomy and bilateral salpingo-oophorectomy (HBSO), and history of a stroke. She presented with right-sided pain and hydro-uretero-nephrosis. Magnetic resonance imaging identified a right adnexal cyst (4.5 × 3.4 × 2.4 cm). She was treated with leuprolide acetate monthly injections and a ureteric stent. The cyst, pain, and hydro-uretero-nephrosis resolved after 12 months. The second case was a 45-year-old woman, G2P2, BMI 28 kg/m(2) with multiple surgeries, including HBSO. She presented with left-sided pelvic pain. Ultrasound identified a left adnexal cyst and hydronephrosis. After 3 months of leuprolide acetate and add-back therapy, the cyst, pain, and hydronephrosis resolved. The third case was a 46-year-old woman, G2P2, BMI 25 kg/m(2), who presented with left flank and pelvic pain. Magnetic resonance imaging indicated moderate left hydronephrosis and left adnexal pelvic side-wall involvement with possible endometriosis. Due to many previous surgeries, this patient was a high-risk surgical candidate, and therefore, she was offered medical therapy. After a normal serum liver and lipid profile, she was started on danazol, 100 mg/day for 3 months. After 3 months of therapy, there was complete resolution of the patient's hydronephrosis and pain. She was then advised to continue with a 3-month on, 3-month off regimen. She discontinued the danazol and remained asymptomatic with no recurrence of hydronephrosis at 3 years.

CONCLUSIONS

Low-dose intermittent danazol or GnRH-a alone or with add-back, may be effective long-term therapies in endometriosis-associated ureteral obstruction when surgery is contraindicated, refused, or difficult to perform.

Endometriosis and infertility

Endometriosis is a debilitating condition characterized by high recurrence rates. The etiology and pathogenesis remain unclear. Typically, endometriosis causes pain and infertility, although 20-25% of patients are asymptomatic. The principal aims of therapy include relief of symptoms, resolution of existing endometriotic implants, and prevention of new foci of ectopic endometrial tissue. Current therapeutic approaches are far from being curative; they focus on managing the clinical symptoms of the disease rather than fighting the disease. Specific combinations of medical, surgical, and psychological treatments can ameliorate the quality of life of women with endometriosis. The benefits of these treatments have not been entirely demonstrated, particularly in terms of expectations that women hold for their own lives. Although theoretically advantageous, there is no evidence that a combination medical-surgical treatment significantly enhances fertility, and it may unnecessarily delay further fertility therapy. Randomized controlled trials are required to demonstrate the efficacy of different treatments.

Treatment of endometriosis with laparoscopic surgery today

Az endometriosis korszerű sebészi kezelésének célja a károsodott kismedencei anatómia helyreállításával az endometriosishoz társuló fájdalomtünetek csökkentése, illetve a teherbe esési esélyek javítása. Cikkünkben a különböző elhelyezkedésű kismedencei endometriosislaesiók eltávolításának műtéti lehetőségeit elemezzük. Az endometriosis sebészi kezelése döntően laparoszkópia útján valósul meg, míg a laparotomia alkalmazási köre egyre inkább beszűkült és csak speciális esetekre korlátozódik. A peritonealis endometriosis laesiói reszekció, elektrokoaguláció vagy lézervaporizáció segítségével kezelhetők, amelyek azonos mértékben csökkentik az endometriosishoz társuló fájdalomtüneteket, illetve javítják a teherbe esési esélyeket. Az endometrioma kezelésében hosszú éveken át kétféle műtéti megoldás terjedt el; a cisztatok eltávolítása az úgynevezett strippingtechnika segítségével, valamint a cisztatok megszüntetése az ablatiós műtéti technikával. Napjainkra egyértelműen bebizonyosodott, hogy a stripping előnyösebb az endometrioma ablatiójával szemben mind a fájdalomtünetek csökkenése, mind a reproduktív funkciók szempontjából. A mélyen infiltráló endometriosis kezelése jelenti a legnagyobb kihívást az endometriosis sebészetében. A mélyen infiltráló laesiók eltávolításában a lézertechnika alkalmazásának jut főszerep. A rectovaginalis septum endometriosisa esetén lézer segítségével a mélyen infiltráló laesio biztonsággal és maradéktalanul eltávolítható. Bélendometriosis esetén az érintett bélszakaszt szegmentális reszekcióval, discreszekcióval vagy az úgynevezett shavingtechnikával távolíthatjuk el. Leggyakrabban a szegmentális reszekciót alkalmazzuk, mivel egyedül ez esetben biztosítható a reszekciós szél biztos épsége. Az ureter endometriosisa esetén kisfokú érintettség mellett ureterolysis, míg obstruktív uropathia fennállásakor az ureter reszekciója javasolható. Az endometriosishoz társuló fájdalom hatékonyabb csökkentését célozza a praesacralis neurectomia és az uterusidegrost-ablatio. Ezen beavatkozások klinikai eredményessége azonban nem egyértelmű, az endometriosis kezelésében betöltött pontos szerepük tisztázása további vizsgálatokat igényel. Az endometriosis sebészetében a folyamatosan fejlődő műtéti technikák az endometriosislaesiók egyre teljesebb és hatékonyabb eltávolítását teszik lehetővé, amelynek köszönhetően egyre eredményesebben kezelhetők az endometriosishoz társuló klinikai tünetek és csökkenthető a betegség kiújulásának veszélye.

Treatment of pelvic pain associated with endometriosis

Pain associated with endometriosis requires careful evaluation to exclude other potential causes and may involve a number of different mechanisms. Both medical and surgical treatments for pain related to endometriosis are effective and choice of treatment must be individualized.

Treatment of pelvic pain associated with endometriosis

Pain associated with endometriosis requires careful evaluation to exclude other potential causes and may involve a number of different mechanisms. Both medical and surgical treatments for pain related to endometriosis are effective and choice of treatment must be individualized.

A randomized trial of excision versus ablation for mild endometriosis

OBJECTIVE

To compare excisional and ablative treatment modalities for mild (revised American Fertility score 1-2) endometriosis in the management of chronic pelvic pain.

DESIGN

A randomized study of excision or ablation for mild endometriosis, participants and investigators alike blinded to the treatment modality at the follow-up visit.

SETTING

District general hospital with a specialist pelvic pain clinic in the United Kingdom.

PATIENT(S)

Women presenting with chronic pelvic pain.

INTERVENTION(S)

Participants were asked to complete a questionnaire detailing symptoms related to chronic pelvic pain and rating their pain on a ranked ordinal scale. Areas of pelvic tenderness were identified and similarly ranked. At laparoscopy they were randomly assigned to excision or ablation of any endometriotic lesions, and the questionnaire was repeated at 6 months.

MAIN OUTCOME MEASURE(S)

Changes in pain score on a ranked ordinal scale after surgical treatment for mild endometriosis.

RESULT(S)

Both treatment modalities produced good symptomatic relief and reduction of pelvic tenderness (67%). There was no difference in morbidity; one woman in each group became pregnant during the study period. Only two participants reported no relief or a worsening of symptoms or signs.

CONCLUSION(S)

This small study showed good symptom relief at 6 months from pelvic pain for the majority of participants irrespective of the treatment modality, but two participants did not improve or got worse. A high pain score before treatment was a predictor of appreciable improvement. Further work is needed to identify women in whom surgical intervention is likely to produce a good response.

An audit of conservative surgery for endometriosis in a district general hospital 1995-1998

As conservative surgery for endometriosis is a relatively new introduction to our hospital we felt it would be of value to audit our results and compare these with results from published series. We sent postal questionnaires to 104 patients who had undergone surgery over the past 3 years to assess their response to treatment. We combined this with an additional questionnaire to patients who had a Laparoscopic uterine nerve ablation (LUNA) procedure. We received replies from 81% of the patients with 81% having symptom improvement following their operation. Eighty-seven per cent of patients who had LUNA returned the questionnaire with 64% having some symptom improvement following surgery. On the basis of our results we will continue to offer conservative surgery for endometriosis as the best primary treatment but have some reservations about the addition of LUNA in patients with endometriosis.

Intestinal endometriosis: the great masquerader

Chronic symptoms of abdominal pain and irregular bowel habits in women evoke a broad differential diagnosis including irritable bowel syndrome, infection, malabsorption, and inflammatory bowel disease. Endometriosis, a common disorder in young women that can involve the intestinal tract, deserves consideration as well. Intestinal endometriosis is typically asymptomatic; however, when symptoms occur, they can mimic those of irritable bowel syndrome. Identifying intestinal endometriosis can be challenging, but historical points and key clinical features aid in diagnosis.

Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III-IV endometriosis and endometriotic cysts

OBJECTIVE

To document the changes in pain scores 3-12 months following ablative laparoscopic surgery. Secondary outcome measures included patient satisfaction scores.

DESIGN

A prospective, cohort study.

SETTING

A tertiary referral center for the treatment of endometriosis.

PATIENT(S)

Seventy-three consecutive women with stage III-IV endometriosis and an endometrioma >2 cm.

INTERVENTION(S)

A laparoscopy was performed. The extraovarian endometriosis was ablated with a CO(2) laser, and the endometrioma capsule was fenestrated then ablated with the potassium-titanic-phosphate (KTP) laser or the Bicap bipolar diathermy.

MAIN OUTCOME MEASURE(S)

Pre- and postoperative visual analogue scores for pelvic pain were completed. Patient satisfaction was scored from 1 to 10, with a score of 10 being "most satisfied."

RESULT(S)

A total of 73 women with stage III-IV endometriosis and 96 cysts (23 cysts were bilateral). The mean revised American Fertility Society (AFS) score was 65.5 (range 22-128). At 12 months, the mean temporal decrease in the pain score for dyspareunia was 2.14 +/- 0.41; for dysmenorrhea, 1.52 +/- 0.38; and for chronic nonmenstrual pain, 2.37 +/- 0.43. Sixty-four (87.7%) patients were satisfied or very satisfied with the treatment. No surgical complications occurred.

CONCLUSION(S)

Laparoscopic ablative surgery for endometriomas in the presence of stage III-IV endometriosis is an effective treatment for relieving pelvic pain.

Future directions in endometriosis research

Future research in endometriosis must focus on pathogenesis studies in the baboon model, the early interactions between endometrial and peritoneal cells in the pelvic cavity at the time of menstruation, and potential differences between eutopic endometrium and myometrium in women with and without endometriosis. More integration is needed between the areas of epidemiology and genetics. Pelvic inflammation in women with endometriosis could be the target for new diagnostic and therapeutic approaches. Important questions remain regarding the relationship between endometriosis and environmental factors. Systemic and extrapelvic manifestations of endometriosis must be analyzed carefully, and better tools are needed to measure quality of life in women with chronic pain caused by endometriosis. Most current evidence supports a causal relationship between endometriosis and subfertility, and the spontaneous progressive nature of endometriosis has been demonstrated in 30% to 60% of patients. Recurrence of endometriosis after classic medical and surgical therapy is a major and underestimated problem, especially in women with advanced disease. Integrated clinical and research teams are needed that combine expert medical, surgical, and holistic care with state-of-the-art research expertise in immunology, endocrinology, and genetics to discover new diagnostic methods and medical treatments for endometriosis.

Diagnosis and treatment of endometriosis

Endometriosis is a chronic and progressive disease that affects approximately 10% of women of reproductive age. Its aetiology remains unknown, however, factors such as retrograde menstruation, heredity, impaired immune function and environmental toxins have been implicated. Laparoscopy is still considered the mainstay for diagnosis, however non-invasive diagnostic methods such as transvaginal ultrasound and MRI may also be complementary. Treatment should be individualised and current treatment options include medical treatment and surgery, however, disease recurrence is common following treatment. Hormonal therapy induces atrophy of endometriotic lesions. Conservative surgery may be successful in removing visible lesions, however in cases of severe or incapacitating illness, removal of the uterus and ovaries may be necessary. In such cases, extreme care must be taken to remove all traces of disease. Experimental treatments for endometriosis show promising preliminary results and include GnRH antagonists, aromatase inhibitors, selective oestrogen receptor modulators and mifepristone.

Recurrence of chocolate cysts after laparoscopic ablation

STUDY OBJECTIVE

To estimate the recurrence rate of chocolate cysts 3 to 12 months after ablative laparoscopic surgery. The secondary outcome measure was the need for a repeat surgical procedure.

DESIGN

Prospective cohort study (Canadian Task Force classification II-2).

SETTING

Tertiary referral center for laparoscopic treatment of endometriosis.

PATIENTS

Seventy-three consecutive women with chocolate cysts larger than 2 cm.

INTERVENTION

Laparoscopy at which cyst capsules were vaporized or coagulated with the potassium-titanyl-phosphate (KTP) laser or Bicap bipolar diathermy.

MEASUREMENTS AND MAIN RESULTS

There were 96 cysts (23 bilateral) in 73 women (1 patient underwent a two-stage procedure). Their mean diameter was 4.79 cm (range 2-25 cm). The median r-AFS score was 56 (range 22-128), and 55 patients (75.3%) had stage 4 disease. The KTP laser was used in 50 women (68.5%) and bipolar diathermy in 23 (31.5%). At 12 months, 5 patients (6.9%) were lost to follow-up, and 12 had a recurrent cyst. Therefore, the cyst recurrence rate/patient was 16.4% (12/73) and the rate/cyst was 12.5% (12/96). Women who had recurrences were significantly more likely to have bilateral cysts, 7/12 (58.3%), than those with single cysts, 16/61 (26.2%, p =0.032). Bicap bipolar diathermy was associated with a recurrence rate of 20.8% (5/24). The rate in women who had KTP laser ablation was 14.3% (7/49, NS). Eighteen patients had repeat operations (including on recurrent cysts). Therefore the reoperation rate was 24.6% (18/73). No major surgical complications occurred. One woman had a postoperative wound infection after a second procedure to remove an ovary with a recurrent cyst.

CONCLUSION

Laparoscopic cyst fenestration followed by capsule ablation is safe and effective treatment for preventing recurrence of chocolate cysts.

Pregnancy rates following ablative laparoscopic surgery for endometriomas

BACKGROUND

In this prospective, cohort study we present the cumulative pregnancy rate following ablative laparoscopic surgery in patients with endometriomas.

METHODS

The cyst was mobilized, fenestrated, and the capsule treated with the potassium-titanyl-phosphate (KTP) laser or bipolar diathermy. Pre- and post-operative transvaginal ultrasound scans were performed, and a detailed fertility history recorded.

RESULTS

There were 39 women (38 intention to treat as a single procedure) who had been trying to conceive for >12 months. The mean age of the patients was 33.8 years (range 20-43), and there were 42 cysts (three bilateral) with a mean diameter of 4.8 cm (range 2-25). The mean revised American Fertility Society score was 64.9 (range 22-124), and 29 (74.4%) patients had stage IV disease. Seven patients (18%) had previously had a live birth, and 17 (43.6%) had undergone assisted conception in the past. The cumulative pregnancy rate was 15/38 (39.5%). The pregnancy rate in patients with stage IV disease was 11/28 (39.3%). There were no major complications.

CONCLUSIONS

Our results indicate that laparoscopic cyst fenestration and capsule ablation is a safe and effective treatment for improving fertility.

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.

A colposcopic approach to an endometriotic nodule in the recto vaginal septum under laparoscopic control

The surgical treatment of endometriotic nodules in the recto vaginal septum is aimed at removing the deeply infiltrating fibro muscular and abnormal glandular tissue, in order to relieve pelvic pain. The laparoscopic approach to the recto vaginal septum is difficult and potentially dangerous. We describe a new mode of access using a combination of laparoscopy and colposcopy. A 20-year-old woman presented with dyspareunia and dyschezia. Vaginal examination revealed a tender nodule, measuring 1.5 <FONT FACE="MetaPress 5">&#50</FONT> 2 cm, in the posterior vagina wall. The endometriotic deposit was positioned at the top of the recto vaginal septum, extending into the posterior vaginal fornix. An air-contrast barium enema and vaginogran (lateral view) excluded a lesion that had penetrated the full thickness of the rectal wall. We carried out colposcopic CO<SUB>2</SUB> laser ablation of the nodule under laparoscopic control. 'Chocolate fluid' spilled from the lesion and the entire nodule was vaporised until normal tissue was reached. The patient was reviewed 3 and 6 months following the operation, and her symptoms had resolved. The colposcope allows an approach into an area of the pelvis that is usually difficult to access.

Surgical management of adhesions, endometriosis, and tubal pathology in the woman with infertility

There are many considerations in the surgical treatment of patients with infertility. Of prime importance is the baseline condition of the tubes and skill of the surgeon. With further advances in the understanding of the process of fertilization and implantation, it is anticipated that the use of surgical methods and application of new technologies will continue to improve fecundity for patients with infertility.

Endometriosis: an overview of the disease and its treatment

OBJECTIVE

To review endometriosis, its etiology, clinical presentation, and current management options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2000) using the search term "endometriosis" and the additional terms "etiology" and "treatment." Additional articles were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

Endometriosis, a disease that affects the physical health and emotional well-being of many women of reproductive age, is defined as the presence of endometrial tissue outside its normal location in the uterus. The disease ranges in severity from mild to severe, and patients may be asymptomatic or experience severe and potentially incapacitating symptoms, such as dysmenorrhea, dyspareunia, and infertility. The diagnosis can be confirmed only by direct visualization using laparoscopy and biopsy. The risk of endometriosis is increased in women who have an affected first-degree relative or who have shorter menstrual cycle lengths, longer duration of menstrual flow, and low parity. The etiology of endometriosis is not yet fully understand, but may involve retrograde menstruation, hereditary factors, and impaired immune function. Treatment should be individualized for each patient, taking into account the therapeutic goals, the extent of disease, symptomatology, and the woman's age and overall health. Treatment options include expectant management, hormonal therapies to suppress ovarian steroidogenesis and induce endometrial atrophy, and surgery to remove visible lesions or, as a last resort, the uterus and ovaries.

CONCLUSION

Although the precise etiology of endometriosis remains a mystery, treatment options have improved considerably in recent years. Pharmacists are well positioned to identify women with unexplained pelvic pain or infertility that may be indicative of endometriosis and refer them to their physicians for further evaluation. Pharmacists also can play an important role in counseling patients about the safe and effective use of the various treatments for this disease and strategies to recognize and reduce adverse effects.

Surgical management of endometriosis

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.

Combined ultrasonographically guided drainage and methotrexate administration for treatment of endometriotic cysts

We report an effective alternative for the management of endometriotic cysts with transabdominal drainage under ultrasonographic control, followed by injection of 30 mg of methotrexate.

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.

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.

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)

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.

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.

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.

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.

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.

Laparoscopic evaluation and treatment of women with chronic pelvic pain

STUDY OBJECTIVE

To evaluate the effectiveness of operative laparoscopic treatment at the time of diagnostic laparoscopy in patients with chronic pelvic pain (CPP).

DESIGN

A retrospective study of women with CPP and at least 6 months of follow-up after laparoscopic evaluation and treatment.

SETTING

A faculty practice and community teaching hospital.

PATIENTS

A series of 65 consecutive women with greater than 1 month of pelvic pain who underwent laparoscopy. Thirty-two were referred by other physicians for evaluation of CPP.

INTERVENTIONS

Patients had operative laparoscopic treatment of all abnormal findings at the time of diagnostic laparoscopy. Nonspecific treatment such as presacral neurectomy or uterine nerve ablation was not performed.

MEASUREMENTS AND MAIN RESULTS

After laparoscopic evaluation and treatment, 78% of patients had decreased pain and 45% were pain free. Prior unsuccessful medical or surgical treatment did not affect the response rate. Endometriosis and adhesive disease were the most common diagnoses, 38% and 34%, respectively.

CONCLUSIONS

Laparoscopic surgical treatment of pathology noted at the time of diagnostic laparoscopy in women with CPP is appropriate, but less than one-half of patients may be expected to have complete pain relief.

Endometriosis and pelvic pain

The majority of patients with pain associated with endometriosis will obtain benefit from the many and varied therapies available for the treatment of endometriosis. The minority who fail to obtain relief from the conventional therapies may obtain benefit from referral to a pain clinic.

An economic evaluation of transcervical endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia

OBJECTIVE

To evaluate the relative health service cost of endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia and the value women attach to their health state before and after surgery.

DESIGN

A prospective economic evaluation running alongside a randomised controlled trial.

SETTING

The gynaecology department of a teaching hospital.

SUBJECTS

200 women requiring surgical treatment of menorrhagia between January 1990 and May 1991; after withdrawals, 97 women underwent hysterectomy and 99 underwent endometrial resection.

MAIN OUTCOME MEASURES

The total health service cost of managing women in the two arms of the trial until 4 months after their operation. The change in women's valuation of their health state a fortnight after and a minimum of 4 months after surgery relative to that 1 month prior to their operation.

RESULTS

Total health service costs are significantly higher amongst abdominal hysterectomy patients (mean 1059.73 pounds) than amongst endometrial resection patients with a mean difference of 499.68 pounds (95% CI 432 pounds-567 pounds). This significant difference exists under alternative assumptions about the difference in lengths of stay in hospital between the two treatment groups and the hotel cost per in-patient day. On a scale of 0 to 100, relative to a month before surgery, there is a statistically significant difference in favour of endometrial resection between the two groups in the increase in value women attach to their health state at a fortnight after surgery (mean difference 11.2; 95% CI 0.6-21.7), but not at a minimum of 4 months after surgery (mean difference 7; 95% CI -17.4 to 3.4).

CONCLUSIONS

On the basis of health service resource cost up to 4 months after surgery, endometrial resection has a cost advantage over abdominal hysterectomy. However, given the fact that a subgroup of women requires retreatment due to resection failure and that this study considers a relatively short period of follow up, the long term costs and benefits of endometrial resection need to be evaluated before widespread diffusion is justified.

Superovulation with human menopausal gonadotropins in the treatment of infertility associated with minimal or mild endometriosis: a controlled randomized study

OBJECTIVE

To determine the efficacy of superovulation with buserelin acetate, human menopausal gonadotropins (hMG), and human chorionic gonadotropin (hCG) in the treatment of infertility associated with minimal or mild endometriosis.

DESIGN

Prospective, randomized, controlled study.

SUBJECTS

Forty-nine infertile women with a laparoscopic diagnosis of endometriosis stage I (n = 29) or II (n = 20) according to the revised American Fertility Society classification, randomly assigned to three superovulation cycles (n = 24) or 6 months' expectant management (n = 25).

MAIN OUTCOME MEASURES

Cycle fecundity rates and cumulative pregnancy rates (CPR) in the two groups.

RESULTS

Nine pregnancies were obtained in the superovulation-treated patients and six in the nontreated ones. The cycle fecundity rates and CPR were 0.15% and 37.4% after three superovulation cycles and 0.045% and 24% after 6 months of expectant management (P less than 0.05 and P = not significant, respectively). The women who did not achieve a pregnancy after three cycles of superovulation were followed for a total of 50 months during which no therapy was given. One pregnancy started in this period (cycle fecundity rate = 0.020). One spontaneous abortion occurred in each group. Three treated patients had multiple pregnancies, and four had ovarian hyperstimulation syndrome.

CONCLUSION

Superovulation seems to be associated with a better cycle fecundity rate but not a better CPR than expectant management in infertile women with endometriosis stages I and II. The efficacy and side effects of this therapeutic approach should be evaluated in larger series.