Current Women’s Health Reviews, 2012, 8, 131-137
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Surgical Treatment of Endometriosis George Michalopoulos1,*, Vassilios Makris2, Angelos Daniilidis2, Chrysanthi Sardeli3, Konstantinos Dinas2, Charilaos Giannoulis2 and P. D. Loufopoulos2 1
Department of Obstetrics and Gynaecology, St John's Hospital, Livingston, Scotland, United Kingdom; 22nd Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Greece; 3 Department of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Greece Abstract: Objective: We review the surgical modalities used in the treatment of endometriosis, including ablative, excisional and denervating. Design: A systematic review of the literature referring to the surgical treatment of endometriosis with emphasis on articles published since 2000. Data sources: Medline, MeSH and Cochrane library searches for terms including “endometriosis”, “ablation”, “excision”, “denervation”, “pelvic pain” and “infertility”. Eligibility criteria: Trials assessing the short, medium and longer-term efficacy of surgical modalities employed in the treatment of endometriosis were considered. Studies published prior to 2000 and small power trials were included only if commonly referenced in the literature. Results: 114 articles were considered with 53 referenced in the final review. Conclusions: Excisional treatment provides more favourable outcomes than drainage and ablation with regards to pain relief, endometrioma recurrence, symptom control and fertility rates. Ancillary surgical procedures such as presacral neurectomy and laparoscopic uterine nerve ablation can prove helpful in the management of dysmenorrhoea. Radical surgery in the form of hysterectomy remains end-stage treatment for endometriosis. The role of medical treatment remains unclear.
Keywords: Ablative, denervating, endometriosis, excisional, laparoscopy, laparotomy. INTRODUCTION Endometriosis is defined as the presence of endometriallike gland and stroma outside the uterine cavity. It occurs in approximately 70% of patients with chronic pelvic pain, dysmenorrhoea and dyspareunia although not all women with endometriosis are symptomatic. Endometriosis is present in 20-40% of women with infertility [1]. It is typically seen during the reproductive years and may have significant physical, psychological and social impact. The annual cost of endometriosis in the USA in 2002 was estimated at $22 billion (Simoens et al., 2007). It has also been reported that 78% of women with endometriosis in the UK lose an average of 5.3 days of work per month due to their disease (Hummelshoj et al., 2006) [2, 3]. The pathogenesis of endometriosis is not fully understood. Several different theories have been suggested including: -
The implantation/transplantation theory: transportation and subsequent implantation of viable endometrial cells in the peritoneal cavity by retrograde menstruation through the fallopian tubes (Sampson, 1927)
*Address correspondence to this author at the Department of Obstetrics and Gynaecology, St John's Hospital at Howden, Livingston EH54 6PP, United Kingdom; Tel: 00447969681405; Fax: 00441506523992; E-mail:
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The induction theory: triggering of a metaplastic process in peritoneal mesenchymal cells by degenerating endometrium (Levander and Normann, 1955).
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The in situ development theory: in situ development of ectopic endometrium from tissue such as remnants of the Wolffian and Müllerian ducts (Lauchlan, 1972).
Endometriosis is most commonly found on the ovaries, fallopian tubes, uterine ligaments and pelvic peritoneum. Less common sites include the bladder, bowel, cervix, rectum, vagina and vulva. Rarely, endometriosis can been found in distant organs such as the lungs, brain, diaphragm, kidneys, spleen, gallbladder, nasal mucosa, spinal canal, stomach, breast and skin. Dissemination can be trans-tubal or through the lymphatic and vascular routes, the latter possibly explaining distal spread. Iatrogenic deposition of endometrial tissue has also been described following both gynaecologic and obstetric procedures [4]. MEDICAL TREATMENT OF ENDOMETRIOSIS Endometriosis can be treated medically or surgically. The aim of endometriosis treatment may include symptomatic relief and/or enhancement of fertility. Medical management is commonly limited to pain control. It can be effective in up to 80-85% of patients but the recurrence rate is high
© 2012 Bentham Science Publishers
132 Current Women’s Health Reviews, 2012, Vol. 8, No. 2
following cessation of treatment. Medical treatments include: -
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen sodium, which reduce pelvic inflammation and menstrual cramping,
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Progestins, for example medroxyprogesterone acetate, norethindrone acetate and norgestrel acetate, which at high doses induce amenorrhoea,
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Combined oral contraceptive pills (OCP), oestrogen and progesterone combinations which among other effects suppress proliferation and enhance programmed cell death (apoptosis) in endometrial tissue,
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Synthetic androgens, such as danazol which by interfering with ovarian production of oestrogen create a chronic anovulatory state, and
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Gonadotrophin-releasing hormone analogues (GnRH-a) which induce amenorrhoea by inhibiting the secretion of gonadotrophins from the pituitary gland.
SURGICAL TREATMENT OF ENDOMETRIOSIS Surgical management of endometriosis can be: -
Conservative, which includes primarily ablative or excisional techniques and adhesiolysis, aiming to conserve the reproductive function, and
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Radical, including total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO).
Ancillary surgical procedures like presacral neurectomy (PSN) or uterine nerve ablation (LUNA/UNA) which interrupt afferent sensory pathways can be used in conjunction with conservative techniques [5]. The aim of conservative surgery, besides establishing the diagnosis, is to destroy or remove endometriotic implants, restore pelvic organ anatomy, relieve symptoms, restore and maintain fertility and delay the recurrence of symptoms.
Michalopoulos et al.
Laparoscopy may be contraindicated in patients with elevated surgical risks including repeat previous surgery. Laparotomy may be preferable when laparoscopy is deemed too hazardous or in the absence of specialist laparoscopic skills [11]. LAPAROSCOPIC METRIOSIS
APPEARANCE
OF
ENDO-
Even an experienced laparoscopic surgeon can miss 7% or underdiagnose 50% of endometriotic lesions [12]. The appearance of endometriosis is a result of the relative proportion of glands and stroma, fibrosis, bleeding of the lesions and quantity of haemosiderin. Endometriosis commonly appears as white lesions (fibromuscular hyperplasia around ectopic endometrial glands and stroma), strawberry-like reddish lesions, red flame-like lesions (neoangiogenesis that implies active implants), reddish polyps, vesicular lesions, adhesions, peritoneal defects, yellow-brown patches on the peritoneal surface and black puckered lesions (black deposits of heamosiderin). Histologically, endometriosis is confirmed in 90% of dark black lesions, 81% of white opacified, 75% of redflame-like, 67% of glandular lesions, 50% of subovarian adhesions 48% of intraovarian cysts, 47% of yellowbrown patches, 45% of circular peritoneal defects, 33% of hemosiderin lesions and 13-15% of macroscopically normal peritoneal biopsies [13, 14]. Non-pigmented lesions are more common in younger women and the darker lesions represent older or “burn out” disease. OVARIAN ENDOMETRIOSIS Endometriomas are not amenable to medical management and in most cases require surgical treatment. However conservative management may be appropriate in cases where concerns exist over reduced ovarian reserve particularly when assisted reproduction is planned.
Laparoscopy is accepted as the gold standard for the diagnosis of endometriosis as it allows for lesion biopsies and benefits from good correlation between operative and histological diagnosis [6-8]. Operative findings however are not necessarily predictive of clinical manifestation, especially in stages I & II of the revised classification of the American Fertility Society (rAFS) [9, 10].
Surgery aims to relieve associated symptoms, prevent recurrence and preserve fertility. Adequate preoperative evaluation is essential in order to exclude malignancy.
Indications for diagnostic laparoscopy for suspected endometriosis include:
Endometriomas >2 cm in diameter should be ideally ressected whole to prevent recurrence. Hydrodissection or repeated cyst expansion and shrinkage with high pressure irrigation (500-800 mmHg) and suction can be used to aid cyst wall separation from the ovarian stroma. Ovarian reconstitution, though not usually necessary in cases of small diameter lesions, may be required for endometriomas >5cm in diameter. Throughout the procedure as much healthy ovarian tissue should be preserved as possible [15, 16].
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Infertility for >1 year without other symptoms or >6 months with co-existing symptoms or in patients over 35 years old.
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Chronic pelvic pain which persists despite 3 months of NSAID treatment or oral contraceptives.
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Imaging suggestive of the presence of endometriomas.
Advantages of laparoscopic surgery include adequate exposure, lesion magnification, minimal tissue handling resulting in reduced inadvertent trauma, lower risk of infection and adhesion formation, less postoperative pain, shorter hospitalisation and quicker return to full activity.
Ovarian endometriotic implants or endometriomas
