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Surgical Removal of Endometriosis: When Is It Worth the Risk?

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Surgical Removal of Endometriosis: When Is It Worth the Risk?

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  1. Surgical Removal of Endometriosis: When Is It Worth the Risk? Tommaso Falcone, M.D. Professor and Chair Obstetrics and Gynecology Cleveland Clinic

  2. LEARNING OBJECTIVES At the conclusion of this presentation, participants should be able to: Assess the outcome (pain relief or pregnancy) of surgical treatment for endometriosis. Discuss different surgical techniques used to treat endometriosis.

  3. DISCLOSURE Nothing to disclose

  4. Symptoms & Signs of advanced endometriosis • Chapron et al 2005 • “Presurgical diagnosis of posterior deep infiltrating endometriosis based on a standardized questionnaire” • Painful defecation during menses • Severe dyspareunia • Previous surgery for endometriosis

  5. Diagnostic work-up • History ( dysmenorrhea, dyspareunia & noncyclic pelvic pain) • Physical exam: adnexal mass, non mobile uterus or cul-de-sac nodularity. • CA-125 • Meta-analysis • Sensitivity of 28 % showed a specificity of 90% • Sensitivity of 50% showed a specificity of 72%

  6. Role of Imaging • Transvaginal ultrasound has a high sensitivity & specificity in the diagnosis of ovarian endometriotic cyst • MR & CT have no added advantage • Trans-rectal ultrasound may have some value for recto-vaginal endometriosis (Fedele et al Obstet & Gynecol 1998) • Imaging has a low sensitivity & specificity for non-ovarian endometriosis

  7. Histologic Diagnosis • Mettler et al. JSLS 2003 • Histologic confirmation in visually identified endometriosis: 54% • “Red” lesions: 100% • “Black” lesions: 92% • “White” lesions: 31% • Sites: least probable on the ovary, bowel serosa, bladder peritoneum

  8. Treatment: Infertile Patient

  9. Treatment Effect • 2 RCTs - Canadian study showed a treatment effect ( inclusion only of women age 20-39 years); Italian study showed no treatment effect. • Combine the studies for pregnancies over 20 weeks: 27% (treated) and 18% ( non-treated): NNT=12 ( 95% CI 6,112) • 20% prevalence of endometriosis • 60 diagnostic laparoscopies to get an extra pregnancy RCTs = randomized controlled trials; NNT = number needed to treat; CI = confidence interval

  10. Moderate-Severe Endometriosis • Candiani et al. 1991 • 206 patients/15 studies: MFR, 3%; CPR, 47% • Luciano et al. 1992: MFR 6.7%; CPR 70% • Busacca et al. J Am Ass Gyn L 1999 • Prospective study: MFR, 2.4%; CPR 24 months, 57% • No RCT • Overall, surgery is not recommended for fertility alone; it can be considered for women under age 35 years. MFR = monthly fecundity rate; CPR = clinical pregnancy rate

  11. Stage III and IV EndometriosisPagidas et al.Fertility and Sterility 1996

  12. Stage III and IV Endometriosis • After initial unsuccessful operative procedure to restore fertility, in vitro fertilization – embryo transfer (IVF-ET) appears to be a superior alternative to re-operation.

  13. Pain Management

  14. Laser Laparoscopy vs. Expectant ManagementSutton et al. Fertil Steril 1994 • 74 women ( Stage I-III) • Prospective randomized double-blind • Significant pain relief compared to expectant management • Non-response rate was 38% • Results were poorest for stage I

  15. RCT scope excision of endo • Abbott et al. F&S 2004 • RCT-placebo trial • Immediate surgery group- 80% response rate at 6 months • Far fewer stage I endometriosis • Delayed surgery group: 30% response rate at 6 months (placebo effect)

  16. Audience Response Question # 1 Please use the text message function on your cell phone.

  17. Success Rate in Teenagers • How do you define “success”? • Yeung et al. F&S 2011 • N=17; 47 % had repeat surgery within 2 years • None had endometriosis

  18. Recurrence Rate • Sutton’s trial F&S 1994 • Follow-up (1 year) after RCT: Treated Group that Improved • 10% recurrence rate • Subsequent surgery showed endometriosis • Abbott et al. Human Reproduction 2003 • 135 patients; Kaplan –Meier survival curve • Average follow-up 3.2 years (range, 2-5 years) • 36% probability of further surgery • 32% had no endometriosis

  19. Reoperation-Free Survival 1.0 .8 .6 Reoperation free survival .4 Laparoscopy Hysterectomy (ovaries preserved) Hysterectomy (ovaries removed) .2 0 1 2 3 4 5 6 7 Years Cleveland Clinic experience. Surgical Treatment of Endometriosis. Obstet Gynecol 2008.

  20. Excision of disease==Reoperation-Free probability 2 Years 5 Years 7 Years HR Versus Factor Frequency (95% CI) (95% CI) (95% CI) (95% CI) Reference Overall Surgery age (y) 19-29 41 65.9 (51.3-80.4) 39.0 (24.1-54.0) 31.7 (17.5-46.0) 1.0 <.001 30-39 93 91.4 (85.7-97.1) 72.0 (62.6-81.3) 62.0 (51.7-72.3) 0.39 (0.24-0.64) <.001 40 or older 72 94.4 (89.2-99.7) 85.8 (77.7-94.0) 83.5 (74.4-92.6) 0.15 (0.07-0.29) <.001

  21. Hysterectomy==Reoperation-Free probability 2 Years 5 Years 7 Years HR Versus Factor Frequency (95% CI) (95% CI) (95% CI) (95% CI) Reference Overall Ages 30-39 Overall 93 91.4 (85.7-97.1) 72.0 (62.6-81.3) 62.0 (51.7-72.3) NA Laparoscopy 50 88.0 (79.0-97.0) 58.0 (44.3-71.7) 43.8 (30.0-57.6) 1.0 .002 ovaries preserved Hysterectomy 22 100.0 (100.0-100.0) 95.2 (86.1-100.0) 89.6 (76.0-100.0) 0.13 (0.03-0.54) .005 ovaries preserved Hysterectomy 21 90.5 (77.9-100.0) 85.7 (70.7-100.0) 85.7 (70.7-100.0) 0.23 (0.07-0.74) .014 ovaries removed

  22. Hysterectomy in Young Women (Less than 30 Years of Age) • Women under age 30 years (compared with women over age 40 years) • 80% felt that hysterectomy had “cured their pain” • 18% had residual symptoms of dyschezia • 18% persistent dysuria • 50% persistent dyspareunia • 56% had a “sense of loss”

  23. Surgical vs. Medical Therapy • Recurrence rate after discontinuing medical therapy is very high. • Placebo rate is approximately 30%.

  24. Prevention of Recurrent Pain • To be effective, you have to use suppressive therapy for long periods of time.

  25. LUNA procedure • Latthe et al. 2007 Systematic Review • No evidence that LUNA adds value to conservative surgery for endometriosis associated pain LUNA = laparoscopic uterine nerve ablation

  26. Robotic Surgery for Endometriosis- • 3 case reports and 1 comparative trial • Nezhat et al. F&S 2010 • N=78; mostly early stage disease; retrospective • Robotic time: 191 minutes • Standard laparosocpy: 159 minutes • No difference in outcome • Longer OR time and larger trocars OR = operating room

  27. Excision versus Ablation • Pregnancy rates similar • Pain relief? • Healy et al. 2010 • Seems equivalent for early stage disease

  28. Endometriosis:Persistence after TAH+BSO • Often seen when endometrial implants not excised • Aromatase expressed in endometriotic lesions • Conversion of adrenal androgens to estrogen locally TAH = total abdominal hysterectomy; BSO = bilateral salpingo-oophorectomy

  29. Failure of Medical Management Persistent Bilateral Ureteral Obstruction Secondary to Endometriosis Despite Treatment with an Aromatase Inhibitor Bohrer et al. F&S 2008

  30. Duodenum Lesion Ureter Aorta IVC

  31. Ureter involvement

  32. Rectosigmoid Endometriosis: • Significant bowel symptoms • Colonoscopy or barium enema normal • May show a stricture • Persistent disease after TAH+BSO is usually rectosigmoid endometriosis