iCareBetter

Why Excision is Recommended

What Is Excision?

Excision is the surgical removal of tissue by cutting out. It differs from ablation/laserization/burning/vaporizing, which are techniques that use a heat source to destroy tissue. Excision allows for a biopsy to be sent to a pathologist for confirmation, and it better ensures that all of the endometriosis lesion is removed. With ablation, it may or may not reach deep enough to destroy all the endometriosis lesions, and it does not allow for pathology confirmation. While ablation may work for superficial endometriosis, it leaves the unknown of whether all of the lesion was truly destroyed. 

There are many tools a surgeon might choose to perform excision, but the tool is only as good as the surgeon who utilizes it. Your surgeon must be able to recognize the many appearances of endometriosis, know all the places to look for endometriosis, and have the ability to remove it from many areas. Some areas are more delicate areas to remove endometriosis (such as ureters, bowel, or diaphragm) and may require a multi-disciplinary team. This is why it is recommended to see someone whose practice consists of regular endometriosis excision.  

Why Excision Is Preferable to Ablation?

“Because there is no objective way of knowing how deeply an endometrial lesion might invade by simply looking at it, the laser surgeon may vaporize the surface of a lesion and still leave active disease below. This is particularly true for deeply invasive nodules of the uterosacral ligaments. In addition, the laser surgeon is frequently reluctant to vaporize disease located over the bowel, bladder, ureters, or major vessels for fear of damaging these organs. Again, active disease can remain in the pelvis and continue to cause pain.

“Because laser vaporization completely destroys tissue suspected of being endometriosis, there is no way to confirm through a pathology report that the vaporized tissue was in fact endometriosis, not some other type of abnormal tissue. This can lead to problems in the scientific study of the disease since the “evidence” presented in a medical journal becomes a matter of opinion rather than a matter of fact. No long-term studies have been published giving data on pain and recurrent disease after laser vaporization. Studies published to date reflect pregnancy outcome, which is misleading when one is treating pain.”  

“The European Society for Human Reproductive Endocrinology guidelines encourage excision, stating that pain due to endometriosis can be reduced by surgical removal of the entire lesion in severe and in deep, infiltrating endometriosis. The guidelines also state that the best approach is to diagnose and remove endometriosis surgically. Despite these recommendations, most surgeons do not excise endometriosis during diagnostic procedures. A recent survey of British gynecologic consultants and surgeons found that only 30% performed surgical removal. In the survey, 95% favored ablative techniques, and 25% used both ablation and excision.7 This reluctance to adopt excision of endometriosis has been judged appropriate by some, due to the lack of good long-term data regarding its effects and the increased potential for surgical complications.

“A review of the literature yields 2 randomized controlled trials (RCTs) and 5 cohort studies addressing the effectiveness of laparoscopic excision for the treatment of endometriosis.8-14 A 2003 study involving 39 subjects with histologically confirmed endometriosis randomized patients to either immediate excisional surgery or diagnostic surgery only.8 All patients underwent second-look laparoscopy, with 80% of women in the excision group reporting improvements in pain symptoms versus 32% in the control group. Women with more advanced disease experienced a greater response to laparoscopic excision. Furthermore, responses on quality-of-life instruments showed significant improvements in both mental and physical scores.8 In the second RCT, 24 women with mild endometriosis (stage 1 or 2) were randomized to either laparoscopic excision or ablation of endometriotic lesions.9 There was no significant difference between groups with respect to pain relief and pelvic tenderness, but there was a significant improvement in the signs of endometriosis (eg, back pain, fatigue, tenderness, adnexal pain) in the excision group. As in the first RCT, the severity of symptoms was the strongest indicator of the success of treatment.8,9 The latter study identified no additional morbidity associated with excision, but both trials were limited by small size and short follow-up.8,9

“There were 5 cohort studies involving laparoscopic excision of endometriosis, 4 of which directly assessed the effects of excisional surgery on pelvic pain (Table).11,12,14-16 A 1996 investigation reported on a 2-year follow-up of women undergoing excision versus laser vaporization. At 12 months, 96% of excision patients and 69% of vaporization patients were pain-free, falling to 69% and 23%, respectively, at 24 months.10 Findings from a study of 135 patients with a mean follow-up of 3.2 years revealed reductions in pain scores related to dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia.11 As expressed by survival curves, the likelihood of avoiding further surgery over the subsequent 5 years was 64%, with the strongest predictive factor for reoperation being a revised American Fertility Score of 70 or higher. Interestingly, endometriosis was not identified at the time of subsequent surgery in 32% of subjects.11 A study that followed 62 women for an average of 13 months reported a 71% satisfaction rate with excision, but 40% of subjects still required regular medication and 11% underwent further surgery.12 Finally, among 107 women treated by laparoscopic excision and followed for a mean of 7.65 years, the 2-, 5-, and 7-year surgery-free rates were 79.2%, 51%, and 41.4%, respectively.14 All of these studies were limited by the lack of a control group, but they consistently showed a 2-year surgery-free rate of more than 70%. Three studies presented data regarding quality of life before and after excision.11,12,17 A 4-month follow-up of 57 consecutive patients undergoing laparoscopic excision of endometriosis reported significant improvement in the physical components of quality-of-life scores, but showed no improvement in the mental components.17 The aforementioned study of 135 patients noted improvement in a quality-of-life scale that persisted through 5 years of follow-up, but these improvements did not reach the quality of life of healthy subjects. 17 Finally, the study that involved 62 patients noted only limited increases in quality-of-life scores, with improvement in social life reported by 32%, in relationships by 24%, and in anxiety levels by 39%.12

“Deep dyspareunia is a common complaint among women with endometriosis, affecting 60% to 79% of patients undergoing surgery.13 An observational prospective cohort study addressed the effects of laparoscopic excision on deep dyspareunia and overall sexual function. The study enrolled 68 women, of whom 87% had stage 3 or 4 disease. At 6 and 12 months’ follow-up, patients demonstrated both significant reductions in the intensity of deep dyspareunia and improvements in the quality of sexual function.13 Two of these studies reported significant improvements in pleasure and comfort.11,13 One RCT comparing laparoscopic endometriosis ablation with diagnostic laparoscopy reported a 62.5% improvement in symptoms at 6 months versus 22% in the control group.15 At a mean followup of 73 months, there was a symptom recurrence rate of 74%, but a 55% rate of satisfactory symptom relief. Whereas the cohort study of 107 patients noted a 2-year reoperation rate of 21.2%, this RCT yielded a median time to symptom recurrence of 19.7 months and a 2-year reoperation of 37%.14,16 Overall, these data have several limitations.

“All of the studies were conducted by expert laparoscopic surgeons, whose results are unlikely to be reproduced by the generalist surgeon. Also, the absence of a control group in the cohort studies limits the significance of their findings. Finally, variations in designs, endpoints, and surgical techniques make it difficult to generalize. There is no definitive study as of yet, and a large, well-designed RCT of laparoscopic excision versus ablation of endometriosis remains to be performed. Based on the studies performed to date, it is the author’s opinion that laparoscopic excision of endometriosis, when technically feasible, should be the standard of care. First, whereas visual diagnosis of endometriosis is correct in only 57% to 72% of cases, excisional surgery yields specimens for histologic confirmation—and identifies endometriosis in 25% of “atypical” pelvic lesions as well.18 The availability of such specimens would prevent unnecessary treatment and ensure more reproducible research findings. Excision should also reduce the incidence of persistent disease secondary to inadequate “tip of the iceberg” destruction, removing both invasive and microscopic endometriosis to provide the best possible symptom relief.

“Finally, the results of excision are comparable to or better than those of ablation. Endometriosis usually recurs, but excision both prolongs the time to reoperation and reduces the severity at second surgery. Excision provides the greatest benefit for patients with extensive disease without increasing complication rates or morbidity Surgical treatment of endometriosis can be difficult due to its tendency to target the uterosacral ligaments adjacent to the ureter and to cause fibrosis and adhesions. However, these complexities need not result in suboptimal debulking of lesions. These studies suggest that converting from ablative to excisional therapy will refine diagnosis, reduce disease burden and morbidity, lengthen the time to recurrence, and improve outcomes overall..”   

Additional Studies on Excision of Endometriosis:

“Laparoscopic endometriosis excision improves quality of life for at least 7 years, even when women have conservative, fertility-sparing surgery, according to a survey study from the University of Pittsburgh.” 

  • Pundir, J., Omanwa, K., Kovoor, E., Pundir, V., Lancaster, G., & Barton-Smith, P. (2017). Laparoscopic excision versus ablation for endometriosis-associated pain: an updated systematic review and meta-analysis. Journal of minimally invasive gynecology, 24(5), 747-756.  Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465017302637  

“The limited available evidence shows that at 12 months postsurgery, symptoms of dysmenorrhea, dyschezia, and chronic pelvic pain secondary to endometriosis showed a significantly greater improvement with laparoscopic excision compared with ablation.”

“The goal of laparoscopic treatment of extensive endometriosis is to excise all visible and palpable endometriosis and to restore normal anatomic relationships. Benefits to the patient include substantial symptom relief and resolution of infertility in many cases, circumvention of major abdominal surgery with its related morbidity, and avoidance of the hypoestrogenic effects of ovarian suppression therapy, which prohibits fertility during its administration and never eradicates deep infiltrating endometriosis. The laparoscopic approach can be lengthy, and the persistent nature of the disease may dictate more than one application. Therefore, determining factors in achieving the desired outcome are the surgeon’s skill and tenacity and the patient’s persistence.”   

  • Yeung Jr, P., Sinervo, K., Winer, W., & Albee Jr, R. B. (2011). Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary?. Fertility and sterility, 95(6), 1909-1912.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21420081 

“Complete laparoscopic excision of endometriosis in teenagers–including areas of typical and atypical endometriosis–has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression. These data have important implications in the overall care of teenagers, regarding pain management, but also potentially for fertility. Further large comparative trials are needed to verify these results.”   

“Conclusion: Patients had significantly improved pain symptoms and quality of life after excision surgery, whether or not DRPs were present. This study demonstrated that a DRP may be a manifestation of endometriosis (even with a clear surface of the pocket), so that DRPs should be excised to achieve optimal excision of endometriosis.”

“Results: There was a reduction in all pain scores over the five-year follow-up in both treatment groups. A significantly greater reduction in dyspareunia VAS scores was seen in the excision group at 5 years (univariate p= .031 and multivariate p=.007). More women went on to use medical treatments for endometriosis amongst the ablation group (p= .004) by 5 years. Conclusions: Surgical treatment of endometriosis provides symptom reduction for up to 5 years. There are some limited areas, such as deep dyspareunia, where excision is more effective than ablation.” 

  • Abbott, J. A., Hawe, J., Clayton, R. D., & Garry, R. (2003). The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow‐up. Human Reproduction, 18(9), 1922-1927. Retrieved from http://humrep.oxfordjournals.org/content/18/9/1922.long 

“CONCLUSIONS: Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life for up to 5 years. The probability of requiring further surgery is 36%. Return of pain following laparoscopic excision is not always associated with clinical evidence of recurrence.”  

  • Santoro, L., D’Onofrio, F., Campo, S., Ferraro, P. M., Flex, A., Angelini, F., … & Landolfi, R. (2014). Regression of endothelial dysfunction in patients with endometriosis after surgical treatment: a 2-year follow-up study. Human Reproduction, 29(6), 1205-1210. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24777848 

“Surgical treatment of endometriosis leads to endothelial function improvement, resulting in reduction of cardiovascular risk.”  

  • Albee Jr, R. B., Sinervo, K., & Fisher, D. T. (2008). Laparoscopic excision of lesions suggestive of endometriosis or otherwise atypical in appearance: the relationship between visual findings and final histologic diagnosis. Journal of Minimally Invasive Gynecology, 15(1), 32-37. Retrieved from http://www.ncbi.nlm.nih.gov/m/pubmed/18262141/ 

“Diagrams detailing appearance, anatomic site, and surgeon’s suspicion of endometriosis versus atypical lesions were compared with final histologic diagnosis. The greatest number of patient lesions were excised from cul-de-sac (n = 309). For this site, using visual criteria for diagnosis of endometriosis, positive predictive value was 93.9%, sensitivity was 69.3%, negative predictive value was 41.9%, and specificity was 83.1%. Prevalence was noted to be 79.0% and accuracy was 72.2%. In addition, atypical-appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 24.3%. In examining tissue specimens from multiple anatomic sites, laparoscopic visual diagnosis of typical endometriosis generally had a high positive predictive value. However, both sensitivity and negative predictive value were lower than expected because of atypical lesions subsequently diagnosed as endometriosis. These data suggest that when the surgical objective is complete eradication of endometriosis, the surgeon must be prepared to excise all lesions suggestive of endometriosis and tissue atypical in appearance as in most anatomic sites approximately 25% of atypical specimens proved to be endometriosis.”  

“Endometriosis could still be regarded as a recurrent disease; nevertheless recurrence could not be ascribed to the retrograde menstruation, but to an incomplete surgical intervention, since it is demonstrated that endometriosis lesions could be also made up of microscopic foci (Redwine, 2003), and or to different timing of growth of the lesions in the same patient, probably due to individual susceptibility that is a typical phenomenon of the diseases inducted by endocrine disruptors (Mori et al., 2003). Therefore surgery, if complete in exhausted growth disease can be considered curative. Contrarily, exposition to endocrine disruptors such as synthetic estrogens or SERM chemical compounds, though reducing the symptoms, could increase the growth of endometriosis.”  

“A systematic review found that post-surgical hormonal treatment of endometriosis compared with surgery alone has no benefit for the outcomes of pain or pregnancy rates, but a significant improvement in disease recurrence in terms of decrease in rAFS score (mean = −2.30; 95% CI = −4.02 to −0.58) (Yap et al., 2004). Overall, however, it found that there is insufficient evidence to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified (Yap et al., 2004)….Moreover, even if post-operation medication proves to be effective in reducing recurrence risk, it is questionable that ‘all’ patients would require such medication in order to reduce the risk of recurrence. It has been reported that about 9% of women with endometriosis simply do not respond to progestin treatment (Vercellini et al., 1997), which may result from progesterone receptor isoform B (PR-B) down-regulation (Attia et al., 2000). If PR-B is silenced due to promoter methylation, as reported in endometriosis (Wu et al., 2006b), progestin treatment or OC use may be of little value since the action of progestins is mediated mostly through PR-B. Therefore, the use of post-operation medication indiscriminately may cause unnecessary side effects (and an increase in health care costs) in some patients who may intrinsically have a much lower risk than others and in others who may be simply resistant to the therapy. The identification of high-risk patients who may benefit the most from drug intervention would remain a challenge. Finally, whether a single medication represents the optimal interventional option is debatable. The recent finding that PR-B and nuclear factor-κB (NF-κB) immunoreactivity jointly constitute a biomarker for recurrence (Shen et al., 2008) suggests the possibility that perhaps a combination of drugs may be superior to a single drug in reducing the risk of recurrence, especially if PR-B is silenced due to promoter methylation.

“Several clinical studies suggest that the recurring endometriotic lesions arise from residual lesions or cells not completely removed during the primary surgery. Nisolle-Pochet et al. (1988) reported that in women who received microsurgical resection of ovarian endometriosis, a high prevalence of active endometriosis without signs of degeneration is found after hormonal therapy. Compared with women receiving no treatment, the mitotic index was similar in women treated for 6 months either with lynestrenol (a progestin), gestrinone (an androgenic, antiestrogenic and antiprogestogenic agent) or buserelin (a GnRH agonist) (Nisolle-Pochet et al., 1988). This suggests that hormonal treatment does not lead to a complete suppression of endometriotic foci and that recurring lesions appear to grow from the residual loci. Vignali et al. (2005) found that for those patients who underwent a second surgery, the recurrence of deep endometriosis is observed in the ‘same’ area of the pelvis involved in the first operation. Exacoustos et al. (2006) reported that of 62 patients with recurrent endometriomas, 50 (80.6%) had a recurrence on the treated ovary, 7 (11.3%) on the contralateral untreated ovary, and 5 (8.1%) on both the treated and untreated ovaries. Overall, the majority of recurrent cases (88.7%) have recurrence involving the treated ovary, suggesting that the recurring cysts seem to grow likely from the residual loci.

 “Above all, this report is directly at odds with the one reporting that recurrent symptoms still occur in about 10% of women even ‘after’ hysterectomy and bilateral scalping-oophorectomy are performed (Namnoum et al., 1995). In fact, some earlier reports also found recurrence after hysterectomy. Sheets and Fetzer (1956) and Andrews and Larsen (1974) reported a 1–3% reoperation rate after hysterectomy with some ovarian conservation. Hammond et al. (1976) reported an 85% reoperation rate 1–5 years after hysterectomy surgery with ovarian conservation. Some anecdotal reports also documented the development of endometriosis after hysterectomy (Goumenou et al., 2003).” 

  • Redwine, D. B. (1991). Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertility and Sterility, 56(4), 628-634. Retrieved from http://europepmc.org/abstract/MED/1833246 

“RESULTS: Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year. CONCLUSION: Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.”  

  • Garry, R., Clayton, R., & Hawe, J. (2000). The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG: An International Journal of Obstetrics & Gynaecology, 107(1), 44-54. Retrieved from https://pubmed.ncbi.nlm.nih.gov/10645861/ 

“Main outcome measures: Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery, and incidence of intra- and post-operative complications. Results: Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life-based on EuroQOL evaluation: EQ-5D (0.595:0.729, P= 0.002) and EQ thermometer (68.9:77.7, P= 0.008); SF12 physical score (44.8:51.9, P= 0.015); sexual activity (habit P= 0.002, pleasure P= 0.002 and discomfort P≤ 0.001). Only the mental health score of SF12 failed to show any statistical improvement (47 1:48.4, P= 0.84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8.0:4.0, P≤ 0.001), pelvic pain (median 7.0:2.0, P≤ 0.001), dyspareunia (median 6.0:0.0, P≤ 0.001) and rectal pain scores (median 4.0:0.0, P≤ 0.001). Complications were noted but were deemed to be acceptable for the extent of the surgery. Conclusions: This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further, follow-up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomized trial.” 

  • Garry, R. (2004). The effectiveness of laparoscopic excision of endometriosis. Current Opinion in Obstetrics and Gynecology, 16(4), 299-303. Retrieved from https://pubmed.ncbi.nlm.nih.gov/15232483/

    “Recent findings: Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. Adjuvant therapies such as the levonorgestrel intrauterine system and pre-sacral neurectomy may further improve outcomes. Ovarian endometriomas are invaginations of the uterine cortex, and surgical stripping of this cortex removes many primordial follicles. Despite this apparent disadvantage, stripping of the capsule is associated with better subsequent pregnancy rates and lower recurrence rates than the more conservative approach of thermal ablation to the superficial cortex. Summary: Laparoscopic excision is currently the ‘gold standard’ approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies.” 
  • Koninckx, P. R., & Martin, D. (1994). Treatment of deeply infiltrating endometriosis. Current opinion in obstetrics and gynecology, 6(3), 231-241. Retrieved from https://europepmc.org/article/med/8038409 

“Surgical excision can be carried out by laparoscopy, laparotomy or vaginally using sharp dissection, electrosurgery or with the use of a CO2 laser. Excision is the treatment of choice because of a high pregnancy rate, a complete cure of pain in most women, and a low recurrence rate….The choice of treatment will therefore depend on the local expertise with minimal invasive surgery, certainly if a first excision has been incomplete and pain symptoms recur.” 

“Which one is better for pelvic pain and recurrence in ovarian endometrioma, excisional surgery versus ablative surgery? A recent Cochrane review evaluated the most effective technique for treating an ovarian endometrioma, either excision of the cyst capsule or drainage followed by electrocoagulation of the cyst wall, measuring the primary outcome as pain symptom improvement [15]. Two randomized studies of the laparoscopic management of ovarian endometrioma, greater than 3 cm were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of dysmenorrhea (OR, 0.15; 95% CI, 0.06 to 0.38), dyspareunia (OR, 0.08; 95% CI, 0.01 to 0.51) and nonmenstrual pelvic pain (OR, 0.10; 95% CI, 0.02 to 0.56). For the secondary outcome measures, laparoscopic excision of the cyst wall was associated with a reduced rate of recurrence of the endometrioma (OR, 0.41; 95% CI, 0.18 to 0.93) and with a reduced requirement for further surgery (OR, 0.21; 95% CI, 0.05 to 0.79) compared with ablative surgery.” 

  • Yeung Jr, P., Tu, F., Bajzak, K., Lamvu, G., Guzovsky, O., Agnelli, R., … & Sinervo, K. (2013). A pilot feasibility multicenter study of patients after excision of endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 17(1), 88. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662751/pdf/jls88.pdf 

“A particular strength of this study is that it describes outcomes after excision for endometriosis from multiple referral centers; as such, it is the first study known to include data from multiple centers after excision. This shows that a multicenter trial is feasible, even among surgical referral sites. Most studies that have been published on excision for the surgical management of endometriosis have been from a single surgeon or center.5,8,9 Patients were suspected to have endometriosis based on the overall assessment of the surgeon from the clinical history and examination findings. One of the benefits of excision is the histologic confirmation of disease, and more than 7 of 10 patients who underwent surgery in this study for the suspicion of endometriosis had histologically proven disease. Even more noteworthy is that of the patients in whom histologically proven endometriosis was found, a high percentage (84.6%) had received either previous hormonal therapy or surgery by ablation as “treatment” for presumed endometriosis, indicating that these interventions are ineffective at suppressing or preventing disease. The data from this study further indicate that the addition of hormonal suppression after excision did not further reduce VAS scores for pain or benefit QOL scores when compared with patients without postoperative hormonal suppression.

“In the RCT of excision versus ablation for endometriosis by Healey et al.5 (2010), differences in pelvic pain were not statistically significant, but there were trends for a difference in bowel-related symptoms and dyspareunia. In addition, as mentioned earlier, the results of their study came from a single center and are likely only applicable to generalist gynecologists. In our prospective multicenter study on excision for endometriosis, there were significant reductions in pelvic pain, dysmenorrhea, dyspareunia, and bladder symptoms but not bowel symptoms. 

“In contrast to the study by Healey et al.,5 where fewer than one-third of patients who underwent surgery previously received either hormonal or surgical treatment, patients in our study received either hormonal or surgical treatment in the vast majority of cases (_80%). One might predict that patients having previous treatment might respond with less benefit from another surgical intervention, yet the rates of improvement in VAS scores were comparable in both studies. Also of note is the finding that patients did not have symptom improvement in QOL scores when no endometriosis was found histologically. A strength of this study is the inclusion of a single validated measure of QOL before and after excision surgery. A scale of 0 to 100 for the QOL score is easy to use and has been validated as an assessment tool.7 Most studies on the surgical management of endometriosis use pelvic pain as the primary outcome as measured by VAS scores.1,3,5 A potential problem with using pelvic pain as the primary outcome of a study on endometriosis is that some components of pain may improve after surgically treating endometriosis whereas others may not, at least to the same extent. A QOL assessment may be a better overall measure of the clinical benefit of surgery for treating endometriosis by translating multiple pain symptoms into a single measure of their effect on daily functioning. In fact, published reviews have recommended the inclusion of a QOL assessment in trials that look at pain as an outcome.10,11 Our study showed a statistically significant improvement in QOL scores after excision at multiple centers. It is our recommendation that a QOL measure be used as the primary symptom outcome measure for future comparative trials on excision versus ablation in the surgical management of endometriosis. This study has produced an estimate of the benefit of QOL after excision to be an increase of 20 points. There are no known studies that have evaluated QOL after ablation. Weaknesses of this study include the skewed actual numbers of recruitment, with more than 58 of 100 patients coming from a single center and 78 of 100 from 2 centers. Perhaps more important is the lack of quality assurance or some objective way to determine whether adequate or complete excision of all areas of abnormal peritoneum was achieved at each of the centers. In any subsequent randomized comparative trial comparing excision and ablation, objective or third-party quality assurance will need to be included for both techniques, especially if a particular referral center favors a particular approach over the other. As reported in a recent study on complete excision of endometriosis in teenagers, one of the most important benefits of excision may not be symptom relief but may be the eradication of the disease.12 Potential eradication of disease by excision might benefit future fertility, and this benefit might need to be evaluated also in a comparative trial of excision versus ablation in the treatment of endometriosis.

“One of the aims of this study was to obtain an estimate of the rate of patients presenting to referral centers for pelvic pain or endometriosis (in particular, centers that specialize in the excision of endometriosis) who would be willing to be randomized to either excision or ablation of endometriosis at the time of surgery. The vast majority of patients (84.0%) were willing to be randomized when asked this question. This bodes well for the feasibility of a randomized comparative trial even at referral centers that specialize in a particular surgical approach to the treatment of endometriosis.

“The results of this study indicate that patients were overwhelmingly willing to be randomized to either excision or ablation for endometriosis even at referral centers, that QOL may be a better overall measure as a primary outcome when one is looking at the benefit of surgery for endometriosis, and that a comparative RCT is feasible, as well as needed, among multiple centers that specialize in surgically treating endometriosis.”  

  • Johnson, N. P., Hummelshoj, L., World Endometriosis Society Montpellier Consortium, Abrao, M. S., Adamson, G. D., Allaire, C., … & Bush, D. (2013). Consensus on current management of endometriosis. Human reproduction, 28(6), 1552-1568. Retrieved from https://academic.oup.com/humrep/article/28/6/1552/603470 

“Laparoscopic surgical removal of endometriosis (through either excision or ablation of endometriosis or both) is an effective first-line approach for treating pain related to endometriosis (Jacobson et al., 2009). Although RCTs have failed to demonstrate the benefit of excision over ablation (Wright et al., 2005; Healey et al., 2010), there is unanimous consensus over the recommendation to excise lesions where possible, especially deep endometriotic lesions, which is felt by most surgeons to give a more thorough removal of disease (Koninckx et al., 2012). It is also acknowledged that, even after expert removal of endometriosis, there may be a recurrence rate of symptoms and endometriotic lesions that varies from 10 to 55% within 12 months (Vercellini et al., 2009), with recurrence affecting _10% of the remaining women each additional year (Guo, 2009). The risk of requirement for repeat surgery is higher in women younger than 30 years at the time of surgery (Shakiba et al., 2008). First operations tend to produce a better response than subsequent surgical procedures, with pain improvements at 6 months in the region of 83% for first excisional procedures versus 53% for second procedures (Abbott et al., 2004). Excessive numbers of repeat laparoscopic procedures should therefore be avoided. The role of a purely diagnostic laparoscopy has been questioned and, ideally, there should always be the option of continuing to surgical removal of endometriosis, within the limitations of the surgeon’s expertise….

“Laparoscopic surgical removal of endometriosis is recognized as being effective in improving fertility in stage I and II endometriosis (Jacobson et al., 2010)… Laparoscopic excision (cystectomy) whenever possible for endometriomas .4 cm in diameter improves fertility more than ablation (drainage and coagulation) (Hart et al., 2008).”  

  • Riley, K. A., Benton, A. S., Deimling, T. A., Kunselman, A. R., & Harkins, G. J. (2019). Surgical excision versus ablation for superficial endometriosis-associated pain: a randomized controlled trial. Journal of Minimally Invasive Gynecology, 26(1), 71-77.  Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465018301808 

“Treatment with ablation improved dysmenorrhea at 6 and 12 months and improved dyspareunia at 6 months as compared with preoperative data. However, only dyspareunia demonstrated a significant difference between ablation and excision. Excision and ablation showed similar effectiveness for the treatment of pain associated with superficial endometriosis, with ablation showing more significant individual changes. Careful patient counseling regarding expectations of surgical intervention is vital in the management of endometriosis.”

Links:

General Outcomes:

Deep Infiltrating Endometriosis (DIE)

Bladder

Reproductive/Pregnancy Outcomes:

Bowel/Gastrointestinal (GI)

Diaphragm/Thoracic

Cul-de-sac

Saeid Gholami

Dr. Saeid Gholami is a medical doctor and the founder of iCareBetter. As a physician, he saw many patients with endometriosis who were suffering. And his patients had to deal with many unanswered questions, misleading information, and the lack of access to qualified experts. For that reason and to combat this issue, he built iCareBetter to optimize how patients and doctors connect.

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