Laparoscopic surgery for endometriosis: a long-term follow-up

OBJECTIVE: To investigate if complete resolution of endometriosis by laparoscopic surgery is beneficial to postoperative fecundity, dysmenorrhea and dyspareunia. DESIGN: An observational comparative study on the outcome of laparoscopic surgery. Patients: Laparoscopically-treated symptomatic women with endometriosis (total n = 236); complete (n = 185) and incomplete (n = 51) surgery groups. MEASUREMENTS: Postoperative fecundity and symptom reduction. RESULTS: With whole populations, no surgical completeness-related difference was observed in cumulative pregnancy rates during the postoperative days 0-400 (cycle fecundity rate = 0.0319). Further accumulation of pregnant cases was followed in the complete surgery group (final cumulative pregnancy rate = 80%), but not in the counterpart group (p = 0.003). The similar result was obtained when only r-AFS classification stages III and IV were compared (p = 0.007). No r-AFS stage-related difference was observed in cumulative pregnancy rates when only patients of complete surgery were selected for comparison. The surgery reduced dysmenorrhea (84.7%) and dyspareunia (80.0%). CONCLUSIONS: Laparoscopic conservative surgery for endometriosis, especially when it is complete, increases fecundity and reduces disease-related symptoms, such as dysmenorrhea and dyspareunia.     

Coagulation versus excision of primary superficial endometriosis: a 2-year follow-up

Objective

Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. We compared the effectiveness of the two laparoscopic methods, coagulation versus excision, for intraperitoneal superficial endometriosis with regard to recurrence and symptom control.

Study design

In a retrospective analysis we evaluated the postoperative follow-up of 79 patients, aged 16–42, with superficial manifestation of endometriosis (median rASRM score 9.2) operated on in the Department of Gynecology and Obstetrics at the Jena University Hospital. Forty-three patients were treated by electrocoagulation and 36 underwent sharp excision. Therapy success was evaluated by using a questionnaire after a mean follow-up of 29 months. Patients were interviewed about pain associated with endometriosis such as dysmenorrhea, dyspareunia, dyschezia and possible medical treatment after surgery. We evaluated the number of surgically proven relapses and questionnaire results using a pain score on an ordinal scale (1–5) for the three categories dysmenorrhea, dyspareunia, and dyschezia.

Results

Both treatment methods resulted in a low number of endometriosis-related symptoms after surgical intervention and in recurrences of 2.8% in the coagulation group and 18.6% in the excision group. The recurrence rate in the coagulation group was lower (p = 0.001). The coagulation group was also presented with a significantly lower postoperative pain score at our long-term follow-up (p = 0.0067).

Conclusion

In cases of superficial endometriosis, laparoscopic surgery achieved low recurrence rates and good symptom control. Compared to sharp excision the use of bipolar electrocoagulation might result in fewer endometriosis-related symptoms as well as fewer relapses with need for surgical re-intervention after a more than 2-year interval. Due to the retrospective, non-randomized character of this study the results should be interpreted carefully. Further prospective studies are needed to assess the value of both surgical approaches in the treatment of endometriosis.     

Surgical treatment of endometriosis

In this review, the pitfalls that still exist with the surgical treatment of endometriosisassociatedpelvic pain have been discussed and the best evidence regarding various aspects of surgical techniques have been reviewed. When laparoscopy is performed to evaluate a woman with pelvic pain symptoms, it is important she be counseled that the primary function of the surgery is to confirm the presence (and allow surgical treatment) of endometriosis, and that it is not the penultimate diagnostic modality for her pelvic pain. There are many etiologies of pelvic pain that present with symptoms resembling those of endometriosis-associated pelvic pain that are not diagnosable with laparoscopy, such as interstitial cystitis and irritable bowel syndrome. It is unfortunate that many women are left with the belief that if a laparoscopy fails to provide a diagnosis of a pain generator, then it means there are no diagnoses other than that the “pain is in her head,” often disparagingly termed “supratentorial” byclinicians. In fact, the pain-related diagnoses that are amenable to and possibly require a laparoscopy are quite limited, a group of diagnoses that this author terms the “dirty dozen” because there are just 12, and only the first 4 have good evidence to clearly associate them with chronic pelvic pain:1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic)9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian.I would argue that diagnostic laparoscopy in modern gynecology has a limited, if any role, and that when laparoscopy is planned for women with chronic pelvic pain, it should be with a very high suspicion of a diagnosis and with plans to treat the disease operatively. In this era, a negative diagnostic laparoscopy should be a rare event.     

Surgical treatment of endometriosis

Ovarian endometriotic cysts with adhesions and rectovaginal endometriosis are absolute indications for laparoscopic surgery. Peritoneal minimal endometriosis is considered a relative indications for surgery by many experts. The discussion is ongoing and more randomized studies are necessary. Ureteral and intestinal endometriosis are indicated for surgery in cases of deep infiltration of the ureteral or intestinal wall. In some cases the GnRH analogue (gonadotropin releasing hormone) can be given as neoadjuvant chemotherapy; after it interval endometriotic debulking is possible. In the case of endometriosis we must apply the same strict rules as in oncology especially as regards negative or positive histological findings.     

Long-term follow-up after conservative surgery for rectovaginal endometriosis

OBJECTIVE: The purpose of this study was to evaluate long-term results in patients who received conservative surgical treatment for rectovaginal endometriosis. STUDY DESIGN: We analyzed the follow-up data for 83 women who underwent surgery for rectovaginal endometriosis. The inclusion criteria were age 20 to 42 years, moderate-to-severe pain symptoms, conservative treatment with retention of the uterus, and at least 1 ovary; the follow-up period was > or =12 months. Kaplan-Meier analysis and Cox regression were used to calculate recurrence rates. RESULTS: The cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment were 28%, 34%, and 27%, respectively. The younger patients had the higher risk of recurrence. Pregnancy had protective effects against the recurrence of symptoms and a need for a new treatment. Patients who underwent bowel resection had fewer recurrences. CONCLUSION: Segmental resection and anastomosis of the bowel, when necessary, improves the outcome without affecting chances of conception. Higher recurrence rates in younger patients seems to justify a more radical treatment in this group of women.     

Bladder endometriosis: laparoscopic treatment and follow-up

OBJECTIVES: This study aims to show the treatment outcome in women affected by isolated bladder endometriosis who underwent laparoscopic surgery in our units. Only women with deep nodules located in the bladder were selected, thus excluding women with deep lesions located in other sites. STUDY DESIGN: Between March 2005 and 2007, women with deep vesical endometriosis, referring to the Departments of Obstetrics and Gynaecology of University Hospitals "G. Martino"of Messina, "Paolo Giaccone"of Palermo and "San Paolo"of Milano, were respectively recruited. A preoperative assessment of the pathology was performed. Women who were concomitantly diagnosed deep nodules of the rectovaginal septum and/or endometriotic ovarian cysts were excluded. A medical therapy with oral contraceptive and/or GnRH analogues was first proposed to the patients affected. If medical treatment failed, a laparoscopic treatment was suggested. We performed a segmental resection of the involved wall or an extramucosal dissection of the bladder according to the cases. A clinical and an instrumental evaluation by ultrasound was performed every 6 months after surgery for the first year and subsequently every 12 months. At the time of referral, patients were also questioned about any recurrence of symptoms. RESULTS: Eight women, with a mean age of 33.8 (range 30-37 years; S.D.=2.5) and a mean parity of 1 (range 0-2) were recruited. Medical therapy failed in all cases and the women underwent laparoscopic treatment. Surgery was complete in all cases without a need for ureteral cannulation. No intraoperative complications occurred. The mean estimated blood loss was 98ml (range 40-200ml). All patients underwent at least the first follow-up assessment. In none of the women, recurrence of bladder endometriotic nodules was documented. In contrast, urinary symptoms were reported in three cases. Nevertheless, all the patients reported improvement of symptoms and declared to be satisfied. CONCLUSIONS: We recommend surgical eradication of bladder lesions. Laparoscopic treatment, in the hands of an expert surgeon, is the management of choice. It offers the best approach to the diagnosis allowing good long-term results, with a less invasive approach. Large multicentric studies are however required prior to drawing definite conclusions.     

Surgical treatment of intrapelvic endometriosis

The paper is a review of the surgical treatment of women intrapelvic endometriosis with attention to the extent of the intervention, the selection of appropriate procedure and employment different techniques and innovations in surgical therapy. Principles of the management of deep infiltrating endometriosis, methods of relieve the pelvic pain and the prevention of postoperative adhesion are also discussed.     

Surgical treatment of endometriosis in the infertile female: a modified approach

Two groups of infertile women underwent conservative surgery for endometriosis, group I (107 patients) prior to 1970 and group II (138 patients) after 1970. To determine whether modifications to the surgical approach after 1970 further increased the likelihood of conception, postoperative pregnancy rates were examined. The data suggest that postoperative pregnancy rates can be improved by (1) removal rather than "repair" of diseased adnexa if the involvement is unilateral and (2) leaving diseased areas undisturbed where excision or cauterization may predispose to the development of postoperative ovarian and/or tubal adhesions. The current surgical technique (used for group II) is described in detail.     

Surgical treatment of symptomatic colorectal endometriosis

The approach to the treatment of bowel endometriosis has varied greatly. In this paper we present 77 consecutive patients with deep colorectal endometriosis treated with a full-thickness resection. Gynecologic procedures included conservative laparotomies for preserving fertility (39 patients); hysterectomy with bilateral salpingo-oophorectomy (29 patients); bilateral salpingo-oophorectomy (2 patients); left salpingo-oophorectomy (1 patient) and resection of pelvic endometriosis in patients with previous ablative surgery (6 patients). A low anterior bowel resection was performed in 68 patients (88.3%); a disc excision of the anterior rectal wall in 5 (6.5%); sigmoid resection in 3 (3.9%), and partial cecal resection in 1 (1.3%). The postoperative febrile morbidity was 10.4%, with no apparent anastomotic leaks. Of 33 patients who attempted to conceive postoperatively, 13 achieved a term pregnancy (39.4%). Complete relief of pelvic symptoms was obtained in 38 patients (49.4%); improvement in 30 (39%); no improvement in 8 (10.4%); and worsening of symptoms in 1 (1.2%). There has been no recurrence of symptomatic bowel endometriosis during 1 to 9 years of follow-up. Full-thickness resection of the colon for the treatment of deep bowel endometriosis is a safe procedure with low morbidity, good postoperative relief of symptoms, and favorable pregnancy rates.     

Surgical treatment of endometriosis: prognostic factors for better quality of life

Abstract

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n?=?42) with SF-12 scores above the median in both physical and mental scales; Group B (n?=?111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26?years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058–1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).     

A comparison between laser surgery and electrosurgery for bilateral hydrosalpinx: a 2-year follow-up

The overall pregnancy rate after salpingostomy in women with complete bilateral terminal tubal occlusions was 26.9%. No difference was found in the intrauterine pregnancy rate and the surgery-conception interval between salpingostomy with the CO2 laser or the microdiathermy needle at a 2-year follow-up. The advantage of the CO2 laser in other reproductive surgery remains to be seen.     

Surgical treatment of endometriosis via laser laparoscopy

The carbon dioxide laser has been used laparoscopically for the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesions in 102 patients. These patients were followed for a period ranging from 12 to 18 months, during which time there were 62 pregnancies, including 9 spontaneous abortions and 1 elective termination. The rates of conception after surgery were as follows: 75% for patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Of 102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy. In this patient group, no immediate or subsequent laparotomy was required before conception was achieved, nor was hormonal therapy enacted during the study period after surgery.     

Surgical treatment of rectovaginal endometriosis with rectal involvement

Rectovaginal endometriosis (RVE) is one of the most serious and incapacitating forms of presentation of this disease. Traditionally, medical treatment has not been considered effective for the majority of patients, being surgery the only reasonable and therapeutic choice in these cases. This exposes patients to a potentially serious morbidity, thus a careful evaluation should be done by a surgical board considering the impact of the disease as well as the quality of life of the patients. The main surgical techniques used are the shaving of the rectal wall affected by the endometriosic implants, the discoid excision of the front rectal wall, and the segmental intestinal resection, and there is no consensus concerning which is the most effective and suitable between them. The bibliography published in the last 10 years relating to the surgical treatment of RVE is being reviewed with the intention of updating the knowledge base about the topic and looking for common ground between different studies, allowing us to come closer to reaching a consensus about treatment for this pathology.     

Simplified colposuspension: a 15-year follow-up

AIM: Retrospective analysis of long-term results of a simplified 'Burch type' colposuspension. METHODS: A retrospective chart review, with follow-up through postal questionnaires sent in September 2000, of all 374 patients who had a simplified colposuspension between 1985 and 1998, with additional total abdominal hysterectomy in 103 patients. Outcome measures were patient satisfaction, complications and recovery. RESULTS: The mean period of follow-up was 9.2 years. Response rate to the questionnaire was 85% with 51.5% of patients very satisfied with the surgery, 17.4% moderately satisfied and 12.6% having some symptomatic relief. Complications developed in 31.3% but few were serious. Average hospitalisation was 5.8 days. The mean time to establishment of normal voiding was 58.5 h. The average length of catheterisation was 49.9 h, with only seven patients requiring prolonged catheterisation. Seventy-four patients required additional surgery for de novo, persistent or recurring symptoms. CONCLUSIONS: The present study provides evidence that a simplified Burch type colposuspension provides a satisfactory cure rate on long-term follow-up and is associated with earlier resumption of normal voiding. Transurethral drainage remains a simple and effective method of bladder management after colposuspension. The present study also confirms that many patients do need further pelvic floor surgery for later development of deficiencies in the pelvic floor.     

Long-term hormonal treatment reduces repetitive surgery for endometriosis recurrence

Research questionHow effective is medical hormonal treatment in preventing endometriosis recurrence and in improving women's clinical symptoms and quality of life?DesignThis observational cross-sectional study evaluated the effects of hormonal medical treatment (progestins, gonadotrophin-releasing hormone analogues or continuous oral contraceptives) on endometriosis recurrence, current clinical symptoms and quality of life in three groups of patients: Group A (n = 34), no hormonal treatment either before or after the first endometriosis surgery; Group B (n = 76), on hormonal treatment after the first endometriosis surgery; and Group C (n = 75), on hormonal treatment both before and after the first endometriosis surgery.ResultsGroup C patients were characterized by a lower rate of endometriosis reoperation (P = 0.011) and a lower rate of dysmenorrhoea (P = 0.006). Women who experienced repetitive endometriosis surgery showed worse physical (P = 0.004) and mental (P = 0.012) status than those who received a single surgery, independent of the treatment.ConclusionHormonal treatments represent a valid cornerstone of endometriosis management and may be useful as an alternative to surgery, but also before surgery, to plan better, and after surgery in order to reduce the risk of recurrence. Medical counselling is very helpful in choosing the correct and individualized endometriosis treatment. In fact, the gold standard for modern endometriosis management is the individualized approach and surgery should be considered, depending on the clinical situation and a patient's symptoms.