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Surgical Management Endometriosis

Jan 2012 – by R. Schenken, MD

Endometriosis may be strongly suspected based on clinical presentation, but laparoscopy remains the gold standard for a definitive diagnosis. In patients with pain that is not improved with medical management, surgery affords an opportunity for both diagnosis and treatment. Surgical therapy may be conservative or definitive. Conservative therapy may include fulguration, laser ablation or excision of endometrial implants, lysis of adhesions, repair of tubal damage, uterosacral nerve ablation and presacral neurectomy. Excision or ablation has been found to significantly reduce pain symptoms over laparoscopy alone, and thus endometriosis should be treated at the time of diagnosis. 1 The decision to excise or ablate is based on the location of the lesion and the comfort level of the surgeon. There is no data showing superiority of one modality over another. In patients with ovarian endometriomas, excision of the entire cyst wall should be performed. Incision and drainage or ablation is not recommended due to the three-fold higher rate of recurrence and reoperation.2 Pain relief is achieved in most patients who undergo laparoscopic ablation/resection of endometriosis and adhesiolysis. However, the risk of recurrence is estimated to be as high as 40 percent at 10 years follow-up and about 20 percent of patients will undergo additional surgery within two years.

Laparoscopic surgery and uterosacral nerve ablation (LUNA) disrupts the parasympathetic ganglia in the uterosacral ligaments which carry pain signals from the uterus, cervix and other pelvic structures. Randomized controlled trials have shown that LUNA at the time of laparoscopy does not decrease pain, dysmenorrhea, dysparunia or dyschezia, and thus LUNA is not recommended.3 Presacral neurectomy (PSN) excises the presacral neural plexus which carries pain signals from the uterus and cervix. A randomized controlled trial of laparoscopic surgery with or without PSN showed that the severity, but not the frequency of pelvic pain, dysmenorrhea and dyspareunia was significantly less at 12 months in women undergoing PSN.4

The term deep infiltrating endometriosis (DIE) describes infiltrative disease that involves the uterosacral ligaments, rectovaginal septum, bowel, ureters, and/or bladder. Medical therapy of symptomatic DIE is usually ineffective or transiently effective, with high recurrence rates. There is no consensus on the extent of resection necessary to treat DIE. Extensive dissection in the rectovaginal septum and rectal/bladder wall dissection, and/or bowel resection is often necessary. Hysterectomy and bilateral salpingoophorectomy alone is inadequate for definitive therapy if endometriosis involving the bowel is left untreated.

Medical therapy after conservative surgery is recommended for patients with pelvic pain to reduce recurrence of pain and reoperation rates. First line therapies include either oral contraceptives or progestins. Continuous oral contraceptives decrease recurrent dysmenorrhea for up to 24 months after surgery. 5 Progestin therapy such as norethindrone acetate, depo medroxyprogesterone acetate (DMPA) and levonorgestrel releasing intrauterine system (LNG-IUS) have all been shown to decrease pain recurrence rates.

Definitive surgical therapy, i.e. hysterectomy with or without bilateral salpingo-oophorectomy, should be reserved for women with severe symptoms who have completed childbearing. A retrospective analysis of patients undergoing hysterectomy for endometriosis showed higher rates of recurrent pain (62% vs. 11%) and need for reoperation (11% vs. 4%) in patients with retained ovarian tissue compared to those with bilateral oophorectomy.6 In premenopausal patients undergoing hysterectomy with bilateral oophorectomy for endometriosis, estrogen therapy (ET) is recommended to reduce symptoms of hypoestrogenism, reduce bone loss and decrease cardiovascular morbidity. Starting ET immediately after surgery does not increase recurrence or reoperation rates.7

References:
1. Busacca M, Marana R, Caruana P, Candiani M, Muzii L, Calia C, Bianchi S. Recurrence of ovarian endometrioma after laparoscopic excision. Am J Obstet Gynecol 1999;180(3):519-523.
2. Vercellini P, Chapron C, De Giorgi O, Consonni D, Frontino G, Crosignani PG. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003(3);188:606.
3. Daniels JP, Middleton L, Xiong T, Champaneria R, Johnson NP, et al. Individual patient data meta-analysis of randomized evidence to assess the effectiveness of laparoscopic uterosacral nerve ablation in chronic pelvic pain. Hum Reprod Update 2010;16(6):568-576.
4. Zullo F, Palomba S, Zupi E, Russo T, Morelli M, Cappiello F, Mastrantonio P. Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1‐year prospective randomized double‐blind controlled trial. Am J Obstet Gynecol 2003;189(1):5-10.
5. Vercellini P, Frontino G, De Giorgi O, Pietropaolo G, Pasin R, Crosignani PG. Continuous Use of an Oral Contraceptive for Endometriosis-Associated Recurrent Dysmenorrhea that does not Respond to a Cyclic Pill Regimen. Fertil Steril 2003;80:560.
6. Namnoum AB, Hickman TN, Goodman SB, Gehlback DL, Rock JA. Incidence of Symptom Recurrence after Hysterectomy for Endometriosis. Fertil Steril 1995;64(5):898-902.
7. Hickman TN, Namnoum AB, Hinton EL, Zacur HA, Rock JA, et al. Timing of estrogen replacement therapy following hysterectomy with oophorectomy for endometriosis. Obstet Gynecol 1998;91(5):673-794.