Surgical treatment of recurrent endometriosis: laparotomy versus laparoscopy. M.Busacca1,2,4, L.Fedele2,3, S.Bianchi1,2,. M.Candiani1,2, B.Agnoli1, ...
Human Reproduction vol.13 no.8 pp.2271–2274, 1998
Surgical treatment of recurrent endometriosis: laparotomy versus laparoscopy
M.Busacca1,2,4, L.Fedele2,3, S.Bianchi1,2, M.Candiani1,2, B.Agnoli1, R.Raffaelli3 and M.Vignali1,2 1Department
of Obstetrics and Gynecology, 2Center for the Study and Cure of Endometriosis, University of Milano and 3Department of Obstetrics and Gynecology, University of Verona, University of Milano, Italy
4To
whom correspondence should be addressed at: Department of Obstetrics and Gynaecology, University of Milano, Via Commenda 12, 20122 Milano, Italy
The objective of this study was to clarify which is the better surgical conservative treatment for recurrent endometriosis. We compared two consecutive surgical series at a tertiary care centre for the cure of endometriosis. The patients were 81 women with recurrent endometriosis, 41 reoperated at laparotomy from 1986 to 1991 and 40 reoperated at laparoscopy from 1992 to 1996. Follow-up after the second operation included clinical and ultrasound examinations performed at least once a year to evaluate the recovery of fertility and the reappearance of symptoms and signs of the disease. The cumulative probability of recurrence of dysmenorrhoea (34 and 43 respectively), and the frequency of recurrence of pelvic pain and dyspareunia and of clinical findings suggestive of the disease were not significantly different in the two groups. The rate of recurrence of dyspareunia was higher in the patients operated at laparotomy as was the number requiring a third operation. However, this could be due to the longer follow-up of this group. No significant difference was observed between the cumulative pregnancy rates at 24 months in the two groups (45 in the laparotomy and 54 in the laparoscopy group). We conclude that operative laparoscopy seems as efficacious as conservative surgery at laparotomy in the treatment of recurrent endometriosis. Key words: endometriosis recurrence/laparoscopy/laparotomy/surgery
Introduction The natural history of endometriosis, like the factors that influence its occurrence and course, has still to be defined. On the other hand, its capacity to recur even after apparently adequate conservative surgery is well known (Punnonen et al., 1980; Wheeler and Malinak, 1983). In fact, the frequency of the recurrence of endometriosis has risen in recent decades as a result of an increasingly widely adopted conservative therapeutic approach. Although definitive surgery is considered the treatment of choice for recurrence, a second conservative © European Society for Human Reproduction and Embryology
intervention is often preferred due to the patient’s young age and her desire for children. In a series of patients treated for recurrent endometriosis at our Department in the 1980s, conservative reoperation at laparotomy was found feasible and was associated with a moderately good recovery of fertility as well as prolonged well-being of the patients (Candiani et al., 1991). Subsequently we decided to perform conservative reoperations on patients with recurrent endometriosis at laparoscopy, based on the experience acquired with this technique in the meantime. The present paper reports a comparative analysis of the two surgical series, treated at laparotomy and laparoscopy, and the results obtained, with the aim of clarifying which is the better conservative treatment for recurrent endometriosis.
Materials and methods This is a comparative analysis of two consecutive series of patients who underwent conservative reoperation for recurrent endometriosis at our Department. In all cases the indication for reoperation was the presence of at least one symptom (pelvic pain or infertility) associated with suspect findings at physical and/or ultrasound examination. Only patients followed for at least 12 months were included. Women who underwent only cyst aspiration and/or adhesiolysis at their first and/ or second operation were excluded as were those who had surgical procedures at the repeat laparoscopy scheduled in the follow-up. Women with suspected endometriosis involving bladder or bowel were excluded from the study and always treated at laparotomy. A total of 81 patients fulfilled these criteria, 41 reoperated at laparotomy from 1986 to 1991 and 40 reoperated at laparoscopy from 1992 to March 1996. In the first period no patient was reoperated for endometriosis at laparoscopy whereas in the second period six women underwent reoperation at laparotomy because of concomitant disease (large myomas in five instances and endometriosis-related hydroureter and hydronephrosis in one); these cases were excluded from the present analysis. Fifty patients had a laparotomy and 31 a laparoscopy at first surgery. The stage of disease at first surgery in patients reoperated at laparotomy was stage I in one case, stage II in three, stage III in 19 and stage IV in 18; i patients reoperated at laparoscopy it was stage I in one case, stage II in two, stage III in 21, stage IV in 16. In the procedures performed at laparotomy, atraumatic surgical techniques were always used to prevent peritoneal adhesions. The walls of endometriomas were always removed completely and the ovarian parenchyma was reconstructed by a deep layer of interrupted stitches and a superficial layer of continuous ones. Accurate haemostasis was obtained with a bipolar coagulator. Presacral neurectomy was performed in four subjects who reported severe midline pain. In the patients who were reoperated at laparoscopy the technique described by Cook and Rock (1991) was adopted. No patient of either group underwent medical treatment before reoperation.
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Endometriosis severity was staged according to the revised American Fertility Society (1985) classification. To evaluate variations in pain symptoms we considered subjects with moderate or severe symptoms before surgery. Before reoperation all the women completed a questionnaire on the presence and severity of dysmenorrhoea and pelvic pain and the presence of deep dyspareunia (Fedele et al., 1993). The severity of dysmenorrhoea and pelvic pain was evaluated according to two scales. One was multidimensional and considered any limitation of daily activities, the coexistence of systemic symptoms and the need for analgesics. On the other scale, a linear one, pain severity was scored from 0 to 10, with 0 indicating the absence of pain, and scores of 1–4, 5–7 and 8–10 mild, moderate and severe pain respectively. All infertile women were investigated before the second operation using a standard diagnostic work-up including a hysterosalpingography, hormone profile (two follicle stimulating hormone, luteinizing hormone and oestradiol in the follicular phase and three progesterone and prolactin assays in the luteal phase), and postcoital test. Further, all partners had two semen analyses to exclude dyspermia. Follow-up after the second operation included clinical and ultrasound examinations performed at least once a year to evaluate the recovery of fertility and the reappearance of symptoms and signs of the disease. At each follow-up visit a standard gynaecological examination and an ultrasound pelvic scan was performed, the occurrence of pregnancy was recorded and any pain symptoms were evaluated on the two scales. The clinical diagnosis of recurrent ovarian endometrioma was done when an ovarian haemorrhagic cyst, with the ultrasonographic characteristics described by Kupfer et al. (1992), was confirmed at ultrasonographic examination 2–3 months after the first ultrasonographic diagnosis. Statistical analysis The basal characteristics of the two groups were compared using Student’s t- and χ2-tests. Recovery of fertility and return of pain symptoms were analysed by the product-limit method and the curves of the two groups were compared with the log-rank test (Armitage and Berry, 1994). The event dates considered in the analysis were the date of reoperation or, in the case of medical therapy after reoperation, the date of its suspension, and the date of the last menstruation in the case of pregnancy or the date of the first menstruation associated with moderate or severe dysmenorrhoea after the second operation.
Results The baseline clinical characteristics of the patients are shown in Table I. The two groups were comparable for age, interval between the two operations, disease stage at reoperation, main complaint, associated infertility factors and concomitant diseases. The only significant difference between them was the length of follow-up (P , 0.01). The mean total, implants and adhesions scores and duration of infertility in the laparotomy and laparotomy group were 39.5 6 22.7 and 36.8 6 25.1, 28.7 6 10.3 and 24.1 6 12.2 months, 16.1 6 14.3 and 12.9 6 15.1, 27.2 6 13.4 and 29.5 6 11.7 months respectively. Patients with stage I or II disease underwent reoperation for the removal of deeply infiltrating endometriosis of the pouch of Douglas or penetrating through the rectovaginal septum. Coexisting pelvic disease was observed in eight patients operated at laparotomy (myomas in five, functional cysts in two) and in six operated at laparoscopy (myomas in four, 2272
Table I. Characteristics of the patients Laparoscopy
Laparotomy
No. of patients Age (years) Length of follow-up (months) Interval between the operations (months) Infertility (n) Associated factors of infertility (n) Dysmenorrhoea (n) Pelvic pain (n) Dyspareunia (n) Stage (n) I II III IV
40 31.8 6 5.5 20.8 6 10.2 60.4 6 50.3
41 31.3 6 5.7 54.1 6 30.1* 47.1 6 40.5
24 7 35 22 16
28 9 32 26 23
6 (15) 2 (5) 21 (53) 11 (28)
2 (5) 0 25 (61) 14 (34)
Postoperative medical treatment (n)
21 (52.5)
25 (61)
(60) (18) (80) (52.5) (37.5)
(68) (22) (78) (63) (56)
*P , 0.01. Values in parentheses are percentages.
Table II. Results in the two treatment groups
Recurrence of Dysmenorrhoeaa Pelvic painb Dyspareuniac Clinical signs Reoperation CDRR at 24 months (%) CPR at 24 months (%)
Laparoscopy (n 5 40)
Laparotomy (n 5 41)
10 7 4 7 2 44 54
7 9 7 9 6 34 45
(28.6) (32) (25) (17.5) (5.4)
(25) (34) (30) (22) (14.6)
a,b,cThe
percentages are calculated on the number of symptomatic patients, i.e. respectively 35, 22, 16 for laparoscopy group and 28, 26, 23 for laparotomy group. CDRR 5 cumulative dysmenorrhoea recurrence rate; CPR 5 cumulative pregnancy rate. Values in parentheses are percentages.
functional cysts in two). Medical treatment after reoperation was given to 25 subjects in the laparotomy group [danazol in 13 cases, gestrinone in two and a gonadotrophin-releasing hormone (GnRH) agonist in 10] and to 21 in the laparoscopy group (a GnRH agonist in 14 cases, danazol in seven). The duration of postoperative medical treatment was 3–6 months. In three patients (7.5%) of the laparoscopy group the reoperation had to be converted to laparotomy because of dense adhesions involving the bowel. Two patients operated at laparotomy had an abdominal wall haematoma in the first postoperative days, whereas no major complications occurred in the patients operated at laparoscopy. Data on reappearance of symptoms and signs and recovery of fertility in the women wanting children are summarized in Table II. Dysmenorrhoea recurred in seven (25%) patients treated at laparotomy who reported the symptom before operation (excluding those who underwent pelvic denervation) and in 10 (28.6%) of those treated laparoscopically. The cumulative probability of recurrence of dysmenorrhoea (34% and 44%, respectively) was not significantly different in the two groups. The frequency of recurrence of pelvic pain and dyspareunia
Recurrent endometriosis
Figure 1. Cumulative pregnancy rate during the first 24 months of follow-up in the two treatment groups.
and of clinical findings suggestive of the disease (nodulation in the pouch of Douglas, tenderness and nodulation of the uterosacral ligaments) was not significantly different in the two groups although the rate of recurrence of dyspareunia was slightly higher in the patients operated at laparotomy as was the number requiring a third operation. Six patients (two of the laparoscopy group and four of the laparotomy group) underwent a third operation because of recurrent ovarian endometriotic cysts and the diagnosis confirmed by histologist. Four patients with ultrasonographic and clinical diagnosis of recurrent ovarian endometriotic cysts (two in the laparoscopy and two in the laparotomy group) were asymptomatic and preferred to delay a third operation. Nine women of the laparotomy group and 10 of the laparoscopy group conceived. All pregnancies obtained were spontaneous pregnancies and were not obtained after assisted reproductive techniques. No significant difference was observed between the cumulative pregnancy rates at 24 months in the two groups (45% and 54% respectively). Figure 1 shows the pattern of recovery of fertility in the two groups. Discussion This analysis showed that operative laparoscopy was as efficacious as surgery at laparotomy in conservative surgical treatment for recurrent endometriosis. In particular, good recovery of fertility and satisfactory pain relief were obtained with the laparoscopic approach. However, some caution is needed in considering our results as a true reflection of reality as this was not a randomized study and the two historical series considered are relatively small. Nevertheless, the characteristics of the two groups were comparable, all the patients underwent surgery at the same department, and, except in some cases with important concomitant disease, the only criterion for the choice of surgical approach was chronological. The mean follow-up of the laparoscopy group was significantly shorter than that of the laparotomy group but statistical analysis by the product-limit method reduced this bias in the evaluation of restored fertility and dysmenorrhoea recurrence. Furthermore, it is generally accepted that the probability of conceiving is
greatest in the first 12–18 months after surgery. On the other hand, the longer follow-up could explain the higher rate of reoperations after the second conservative surgical intervention at laparotomy. A potential criticism of our study is that, as laparoscopy is a less invasive procedure, it could have been proposed by the surgeon also for patients for whom a second operation at laparotomy would not have been considered. However, the disease severity at reoperation was similar in the two groups. To our knowledge, no larger series has been described in the literature on conservative treatment for recurrent endometriosis. The results obtained are similar to those reported in a previous study of ours (Candiani et al., 1991) that included some of the present patients, confirming that pregnancy is achieved in about half of infertile women and well-being in most others after a second conservative operation regardless of the surgical route. Various authors have observed a moderately good recovery of infertility (crude pregnancy rate from 20% to 47%) after conservative surgery at laparotomy for recurrent endometriosis (Wheeler and Malinak, 1983, 1987; Evers et al., 1990; Redwine, 1991). So far no data have been published on the efficacy of operative laparoscopy for recurrent endometriosis although many authors have reported results similar if not superior to those of surgery at laparotomy in terms of restored fertility and pain relief in women with a first diagnosis of endometriosis (Gant, 1992; Adamson and Pasta, 1994; Bateman et al., 1994; Crosignani et al., 1994; Balasch et al., 1996; Chapron and Dubuisson, 1996). Our findings suggest that this method may be adequate also for patients with recurrence of endometriosis. Unfortunately, pain symptoms recurred in ~30 of patients in both groups, and eight patients (two operated at laparoscopy and six at laparotomy) had to undergo a third operation. This confirms the aggressive character that endometriosis tends to have in at least some patients for whom the best that conservative treatment will do is allow a disease- and symptom-free interval during which conception may be attempted. Although this aim may be relatively limited, we always consider a second conservative intervention opportune, also because at present it is not possible to differentiate between patients with favourable and negative prognosis. In three patients of the laparoscopy group the operation was converted to laparotomy because of the difficulties encountered in dissecting the adhesions involving large endometriomas and the bowel. In these cases we considered open abdominal surgery less difficult and safer. However, laparoscopic surgery was feasible and allowed complete removal of endometriotic lesions in all the remaining patients with severe disease (n 5 8). The experience and skill of the endoscopic surgeon are critical in determining recourse to laparotomy. All the interventions on our patients were carried out by four surgeons with similar experience in the treatment of endometriosis who used the same basic surgical techniques at laparotomy and laparoscopy. At present the laparoscopic route is used for .90% of operations done for endometriosis at our department. According to Cook and Rock (1991), laparotomy should be performed whenever cleavage planes cannot be identified clearly at laparoscopy and/or optimal conservative surgery is 2273
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not feasible. In the other cases laparoscopy allows a detailed visualization of pelvic anatomy, and gentle handling and precise dissection of the tissues. This paper does not include data on the difference in postoperative morbidity and hospital stay between the laparoscopy and laparotomy groups, but the advantages of laparoscopy have already been extensively demonstrated. The availability of an efficacious and minimally invasive surgical technique makes the appropriateness of the current therapeutic alternatives for recurrent endometriosis highly controversial. It is currently believed that infertile women with recurrent endometriosis should be included in assisted reproduction programmes. However, the poor results of these techniques and their cost make operative laparoscopy the treatment of choice in such women. Likewise, operative laparoscopy seems to offer notable advantages with respect to repeated courses of medical therapy which are necessary for patients with pelvic pain associated with recurrent endometriosis. Unfortunately, the effect of the pharmacological treatments now available usually disappears shortly after their suspension. In addition, these drugs may be expensive and have frequent adverse reactions. In conclusion, operative laparoscopy is as efficacious in the treatment of recurrent endometriosis as it is in the treatment of the primary disease, and simplifies management of the disease for the clinician. References Adamson, G.D. and Pasta, D.J. (1994) Surgical treatment of endometriosisassociated infertility: meta-analysis compared with survival analysis. Am. J. Obstet. Gynecol., 171, 1488–1505. American Fertility Society (1985) Revised American Fertility Society Classification of Endometriosis: 1985. Fertil. Steril., 43, 351–352. Armitage, P. and Berry, G. (1994) Statistical Methods in Medical Research, 3rd edn. Blackwell, London. Balasch, J., Creus, M., Fabregues, F. et al. (1996) Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study. Hum. Reprod., 11, 387–391. Bateman, B.G., Kolp, L.A. and Mills, S. (1994) Endoscopic versus laparotomy management of endometriomas. Fertil. Steril., 62, 690–695. Candiani, G.B., Fedele, L.,Vercellini, P. et al. (1991) Repetitive conservative surgery for recurrence of endometriosis. Obstet. Gynecol., 77, 421–424. Chapron, C. and Dubuisson, J.B. (1996) Laparoscopic treatment of deep endometriosis located on the uterosacral ligaments. Hum. Reprod., 11, 868–873. Cook, A.S. and Rock, J.A. (1991) The role of laparoscopy in the treatment of endometriosis. Fertil. Steril., 55, 663–680. Crosignani, P.G., Vercellini, P., Biffignandi, F. et al. (1996) Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis. Fertil. Steril., 66, 706–710. Evers, J.L.H., Dunselman, G.A.J., Land, J.A. and Bouckaert, P.X.J.M. (1990) Endometriosis: the management of recurrent disease. In Shaw, R.W. (ed.), Endometriosis. Parthenon Publishing, Carnforth, UK, pp. 93–105. Fedele, L., Bianchi, S., Bocciolone, L. et al. (1993) Buserelin in the treatment of pelvic pain associated with minimal and mild endometriosis: a controlled study. Fertil. Steril., 59, 516–521. Gant, N.F. (1992) Infertility and endometriosis: comparison of pregnancy outcomes with laparotomy versus laparoscopic techniques. Am. J. Obstet. Gynecol., 166, 1072–1081. Kupfer, M.C., Schiwimer, R.S. and Lebovic, J. (1992) Transvaginal sonographic appearance of endometriomata: spectrum of findings. J. Ultrasound Med., 11, 129–132. Punnonen, R., Klemi, P. and Nikkanen, V. (1980) Recurrent endometriosis. Gynecol. Obstet. Invest., 11, 307–312. Redwine, D.B. (1991) Conservative laparoscopic excision of endometriosis
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by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil. Steril., 56, 628–634. Wheeler, J.M. and Malinak, L.R. (1983) Recurrent endometriosis: incidence, management and prognosis. Am. J. Obstet. Gynecol., 146, 247–253. Wheeler, J.M. and Malinak, L.R. (1987) Recurrent endometriosis. Contrib. Gynecol. Obstet., 16, 13–21. Received on December 12, 1997; accepted on May 26, 1998
