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

doi:10.1016/j.ejogrb.2010.02.022

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 150, Issue 2, June 2010, Pages 195-198

https://doi.org/10.1016/j.ejogrb.2010.02.022 Get rights and content

Abstract

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.

Introduction

Endometriosis is a common disease of women during their reproductive years. It is characterised by the occurrence of endometrial glands and stroma outside the uterine cavity. Symptoms include dysmenorrhea, dyspareunia, dyschezia, and subfertility. This disease affects 5–10% of all women and 17% of all patients with subfertility [1]. Symptomatic endometriosis may be treated either surgically or medically. In severe cases, e.g. with bowel stenosis, a surgical approach with excision of the lesion is regarded as treatment of choice. In cases of mild symptomatic endometriosis, advocates of a surgical approach argue that a minimal invasive intervention is preferable to prolonged medical treatment, often associated with considerable undesirable side effects. Furthermore, in cases of women seeking conception, surgery is often the only therapeutic option since medical treatment frequently interferes with ovulation. Proponents of medical treatment reason that in a majority of cases control of pain can be effectively achieved by use of oral contraceptives or progestins. Surgical interventions therefore should be reserved for non-responders as well as symptomatic women with a desire to have children [2]. Both positions are subject of a vivid ongoing debate.

With regard to surgical treatment, operative modalities include sharp excision of affected areas and unipolar or bipolar electrocoagulation. Recently, the use of CO₂-laser has been introduced as an alternative surgical treatment option.

Although these techniques are being widely used, few studies investigated their effectiveness. In 1979, Hasson [3] showed that electrocoagulation of pelvic endometriotic lesions can be an adequate therapy for chronic pelvic pain or infertility caused by endometriosis. The effectiveness of these treatments has been further studied in the last few years. Whereas laparoscopic surgery has been proven an effective treatment of endometriosis [4], [5], the ablative techniques used thereby are still being discussed controversially.

The two most common laparoscopic techniques, excision and coagulation, have been compared to each other in various studies. Sufficient data can be found for treating deeply infiltrating endometriosis as well as for endometriotic cysts of the ovary. However, the question which technique is suited best to treat the most frequently diagnosed form of superficial endometriosis remains undecided. In our study, we compared the outcome of coagulation and excision of endometriotic lesions in patients with superficial endometriosis.

Section snippets

Material and methods

One hundred and thirty-seven women were treated by laparoscopic surgery from 2003 until 2007 in our hospital for symptomatic superficial peritoneal endometriosis. For our study we evaluated only patients who had not received any endometriosis-specific surgical or medical treatment prior to laparoscopic intervention at our department. All patients contacted consented to a follow-up interview. A total of 79 patients were included in our study.

The clinically suspected diagnosis was verified

Results

Patients were aged 16–42 years at the time of diagnosis (mean 25 years in the excision group and 23 years in the coagulation group). All patients reported characteristic symptoms of endometriosis such as dysmenorrhea, pelvic pain, dyspareunia or dyschezia at the time of surgical treatment. Medical treatment regimes with non-steroidal anti-inflammatories (NSAI) and spasmolytics had not resulted in sufficient pain relief before. All women had otherwise been in good physical health.

Recurrences

Comments

In earlier studies long-term effectiveness of endoscopic therapy of superficial endometriosis has been well established. Especially in comparison with the medical treatment of endometriosis by GnRH-analogues, a distinct improvement in the outcome could be seen after surgical treatment. Recurrence of endometriosis in patients treated with GNRH-analogues was shown in 35–40% of early stages and in 70–75% of severe stages during a surveillance of 5 years [8]. In our study, we found an overall

Acknowledgments

The authors wish to thank Dr. Wolfgang Michels, mathematician, for assistance in the statistical analysis, Dr. Mieczyslaw Gajda, pathologist, for histological analyses and Ms. Magdalena Dorfmeister, medical student, for assistance in elaboration of the manuscript. MPR was funded by a stipend of the Interdisciplinary Center of Clinical Research (IZKF), University of Jena.

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Surgical Considerations in the Management of Adolescent Endometriosis—An Expert Commentary
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Given the complexities and controversies that exist in diagnosing adult endometriosis, as well as optimizing medical and surgical management, it is not surprising that there is even more ambiguity and inconsistency in the optimal surgical care of endometriosis in the adolescent. This collaborative commentary aimed to provide evidence-based recommendations optimizing the role of surgical interventions for endometriosis in the adolescent patient with input from experts in minimally invasive gynecologic surgery, pediatric and adolescent gynecology, and infertility/reproductive medicine.
Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis
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Citation Excerpt :
In contrast to Pundir et al [18], we decided not to include Barton-Smith et al [22] owing to the fact that it is a doctoral thesis examining excision vs ablation and has not been published in a peer-reviewed publication. In addition, we included Radosa et al [29], a retrospective study that followed women for 2 years after surgical management of mild endometriosis, and Riley et al [30], an RCT assessing excision and ablation that was published in 2019. On critical appraisal of the 4 studies included, the current evidence does not reveal a significant difference in postoperative endometriosis-related pain between excision and ablation for the management of minimal to mild endometriosis.
The aim of this systematic review and meta-analysis was to perform an updated analysis of the literature in regard to the surgical management of minimal to mild endometriosis. This study evaluated women of reproductive age with superficial endometriosis to determine if the results of surgical excision compared with those of ablation in improved pain scores postoperatively.
The following databases were searched from inception to May 2020 for relevant studies: Cochrane Central Register of Controlled Trials, PubMed (MEDLINE), Ovid (MEDLINE), Scopus, and Web of Science.
From our literature search, a total of 2633 articles were identified and screened. Ultimately, 4 randomized controlled trials were selected and included in our systematic review. The combined total number of subjects was 346 from these 4 studies, with sample sizes ranging from 24 to 170 participants. Data from 3 of the included studies were able to be compared and analyzed for a meta-analysis. The primary outcome was reduction in the visual analog scale (VAS) score for endometriosis-associated pain (dysmenorrhea, dyschezia, and dyspareunia), with follow-up time ranging from 6 to 60 months postoperatively.
Data extracted from each study included the mean reduction in the VAS score from baseline. A random-effects model was used owing to significant heterogeneity across the studies. Statistical analyses were performed using Review Manager 5.3 software (Cochrane Collaboration, London, United Kingdom). The meta-analyses showed no significant differences between the excision and ablation groups in the mean reduction in VAS scores from baseline to 12 months postoperatively for dysmenorrhea (mean difference [MD] –0.03; 95% confidence interval [CI], –1.27 to 1.22; p = .97), dyschezia (MD 0.46; 95% CI, –1.09 to 2.02; p = .56), and dyspareunia (MD 0.10; 95% CI, –2.36 to 2.56; p = .94). In addition, there were no significant differences between the excision and ablation groups in mean VAS scores at the 12-month follow-up and beyond for dysmenorrhea (MD –0.11; 95% CI, –2.14 to 1.93; p = .92), dyschezia (MD 0.01; 95% CI, –0.70 to 0.72; p = .99), and dyspareunia (MD 0.34; 95% CI, –1.61 to 2.30; p = .73).
On the basis of the data from our systematic review and pooled meta-analysis, no significant difference between laparoscopic excision and ablation was noted in regard to improving pain from minimal to mild endometriosis. However, to make definitive conclusions on this topic, larger randomized controlled trials are needed with longer follow-up.
To excise or ablate endometriosis? A prospective randomized double-blinded trial after 5-year follow-up
2014, Journal of Minimally Invasive Gynecology
To compare reduction of pain after laparoscopy for ablation or excision of endometriosis.
Prospective, randomized, double-blind study (Canadian Task Force classification I).
Endometriosis and pelvic pain clinic at a university teaching hospital.
Women of reproductive age with pelvic pain and visually proved endometriosis.
Subjects completed a questionnaire rating various kinds of pain using visual analog scales (VAS). After visual identification subjects were randomized to treatment via ablation or excision by supervised training gynecologists as primary surgeons. Follow-up questionnaires documented pain levels every 3 months for 1 year and then every 6 months for 5 years.
Change in pain VAS scores during 5 years after the operation and rates of pregnancy, repeat surgery, and use of hormone therapy were evaluated. There was a reduction in all pain scores over the 5-year follow-up in both treatment groups. A significantly greater reduction in dyspareunia VAS scores was observed in the excision group at 5 years (p = .03 at univariate analysis, and p = .007 at multivariate analysis). More women in the ablation group continued to receive medical treatment of endometriosis at 5 years (p = .004).
Surgical treatment of endometriosis provides symptom reduction for up to 5 years. In some limited areas such as deep dyspareunia, excision is more effective than ablation.
Laparoscopy in Pregnancy and the Pediatric Patient
2011, Obstetrics and Gynecology Clinics of North America
Possible Role of the Posterior Compartment Peritonectomy, as a Part of the Complex Surgery, Regarding Recurrence Rate, Improvement of Symptoms and Fertility Rate in Patients with Endometriosis, Long-Term Follow-Up
2020, Journal of Minimally Invasive Gynecology
Beside the pain, there are 2 further problems in the management of endometriosis: the high recurrence rate (10% per year) and the high rate of impaired fertility. The objective of this study was to investigate the pathogenesis of these 2 factors.
This is a retrospective cohort study, and the aim is to evaluate the complete excision of endometriotic lesions, including the posterior compartment of the peritoneum, with regard to postoperative outcome, focusing on relieving pain, increasing fertility rate, and decreasing recurrence rate.
Charité-University Clinic, Department of Gynaecology, Endometriosis research Centre.
Fifty-four patients were enrolled in this study, with severe deep infiltrating endometriosis (scored by ENZIAN) and superficial endometriosis, as well as endometriomas (revised American Society for Reproductive Medicine [rASRM] I = 3; II = 15; III = 10; and IV = 26).
Posterior compartment peritonectomy (visible endometriotic lesions and inflamed altered peritoneum) was performed in all patients as part of a complex surgery: complete excision of endometriosis.
Postoperative outcomes were evaluated, based on the postoperative follow-up (up to 5 years) of 54 investigated patients. In 36 women (66%) preoperative complaints were eliminated. Furthermore, of 28 women seeking improved fertility, pregnancy was reported in 13 cases (46%). In 7 (54%) cases pregnancy occurred spontaneously, and in the remainder with assisted fertilization. In addition, long-term follow-up demonstrated a recurrence rate in 1.8% of patients.
Overall, the number of complaints was significantly reduced. Only in the case of reproductive-aged women with ongoing postoperative complaints was it important to preserve the uterus. Although this pilot study on systematic posterior peritonectomy showed improvement in recurrence and fertility rate, the main question remains: will this surgical technique achieve better results and outcomes in the future? This has to be addressed in a prospective randomized study.
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Coagulation versus excision of primary superficial endometriosis: a 2-year follow-up

Abstract

Objective

Study design

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Comments

Acknowledgments

Fertil Steril

Best Pract Res Clin Obstet Gynaecol

Am J Obstet Gynecol

Fertil Steril

Fertil Steril

Pain

Obstet Gynecol Clin North Am

Fertil Steril

J Minim Invasive Gynecol

J Am Assoc Gynecol Laparosc

Fertil Steril

Fertil Steril

Reprod Biomed Online