The case for surgery for endometriosis

Dr Sinervo is Medical Director of the Center for Endometriosis Care, Atlanta, Georgia.

He has no conflict of interest to disclose with respect to the content of this article.

Endometriosis is a challenging entity affecting an estimated 176 million women worldwide.¹ Associated symptoms include significant pain, infertility, dysuria, dysmenorrhea, dyspareunia, dyschezia, and other physical and quality-of-life issues. Comprehensive clinical evaluation is strongly recommended for early and accurate detection in order to afford timely management.

Although signs of endometriosis can occur during adolescence, diagnosis is often delayed for years, with knowledge deficits contributing to consequential diagnostic delays, suboptimal treatments, and poor outcomes. Treatment mainstays include analgesic, surgical, and medical approaches, alone or in combination. Several guidelines have been developed by various consortia, but controversy and uncertainty over best practice for treatment remain.²

Unfortunately, therapy is often ineffective and incomplete, with high rates of recurrence when the disease is left intact. Hence, it is my opinion that laparoscopic excision (LAPEX) is and should remain the standard of care. The quality of the surgery, not necessarily the procedure per se, holds the key to conclusively treating endometriosis.

Diagnostic approaches

An evaluation of symptoms combined with physical findings is insufficient to confirm or exclude the presence of disease, and a lack of noninvasive options further limits the diagnostic process. Surgical evaluation with histologic confirmation is the definitive means of obtaining true diagnosis.

Hormonal suppression, which may temporarily improve symptoms in some patients, should not be used to “diagnose” endometriosis and has never been demonstrated as effective in preventing recurrence or improving fertility.³ Indeed, not all pelvic pain has as its source endometriosis (or endometriosis alone), so we must take a methodical approach to ruling out other obvious pathologies. Non-classic signs (ie, soft tissue, lung or diaphragmatic disease, or symptomatology limited to bowel or bladder), however, should not be undervalued. To that end, complete resection of all visible foci offers the best means of biopsy diagnosis and symptom control.

Some patients may benefit from careful surgical assessment and intervention by specialists, but unfortunately, such referrals are often injudiciously withheld (particularly in primary care/generalist settings and or adolescents) due to lack of understanding across all disciplines.

A 3-mm diagnostic scope, however, could spare a patient who does not have endometriosis from potentially long intervals of expensive, uncomfortable, and hazardous medical treatment(s).⁴ Medical “diagnosis” and “management” of endometriosis may continue to lead to further diagnostic and definitive treatment delays-and patient dissatisfaction-when a strategy of “treat without seeing” is adopted.

The LAPEX approach

LAPEX is a minimally invasive gynecologic surgery strongly associated with symptomatic improvements in general health, sexual function, fertility, and quality of life in those struggling with endometriosis,⁵ with complete excision preventing persistent disease in many cases.⁶ Inadequately treated, however, endometriosis may lead to continued pain, infertility, substantial dysfunction and decreased quality of life, costly in-patient stays, postoperative morbidity, reduced productivity and, ultimately, poor outcomes. This contributes to an unnecessary financial burden on the patient, hospital provider, practitioner, and society.

The high rates of recurrence associated with endometriosis surgery in the literature strongly depend on the completeness of disease removal. LAPEX is a well-established yet under-practiced approach, with the goal at time of surgery to completely resect all disease, restore normal anatomy, and apply measures for adhesion prevention.

Data suggest that the surgical objective should be complete eradication; therefore, the surgeon must be prepared to excise all lesions suggestive of endometriosis as well as all atypical tissue, because in most anatomic sites, approximately 50% of atypical specimens prove to be endometriosis.⁴ Despite its proven efficacy, surgical treatment is not without peril, and many surgeons may be unprepared for such an undertaking; hence, timely referral to a center of expertise in endometriosis is warranted. Despite its increased degree of technical difficulty, LAPEX remains the most minimally invasive, cost-effective option.

Complete resection offers the best reduction and control of symptoms, even in teenagers; results do not depend on postoperative hormonal suppression.^7,8 Further reviews have demonstrated that surgical management is effective in treatment of painful symptoms and dysfunction as well as subfertility, and evidence supports laparoscopic intervention as the primary treatment modality for all stages of disease.⁹

Medical therapy versus excision

As has been suggested in the literature, persistent emphasis on medical treatment for endometriosis may be misleading and result in physicians mismanaging their patients.⁹ Data indicate that little difference exists in effectiveness of the various analogs, all of which last only while the patient is undergoing treatment and most of which have negative side effects. Early disease does not disappear under suppressive treatment yet may also not progress; hence use of oral contraceptives or progestins may be successful in temporary suppression. However, in the interest of patient-centered care, the decision to use medical therapy should be made by a woman after all options have been reviewed.

All medical therapy, whether administered as first-line treatment or postoperatively, is associated with high rates of disease recurrence.^10,11 Surgery, on the other hand, provides symptom reduction for up to 5 years, with studies indicating that excision is more effective than ablation. Moreover, one recent prospective, randomized, double-blind study revealed that more patients in the ablation group continued to receive medical treatment at 5 years.¹² While systematic literature reviews report rates of pain recurrence as high as 50% at 1 to 2 years after surgery for symptomatic endometriosis,¹³ that is likely due to the nature of the surgery and the surgeon’s skill. Incomplete excision is the predominant reason for disease recurrence, with return of pain and symptoms directly correlated to surgical precision and removal of peritoneal and deeply infiltrating disease. The goal should be to eradicate disease completely in order to keep risk of recurrence as low as possible.¹⁴

The assumption that all surgery is performed by surgeons of similar caliber and experience is inaccurate, and such postulation does not address the issue of success in removing all disease at the time of surgery, ignoring the excellent results of truly skilled excisionists with adequate experience in recognition and total resection. The success of treatment indeed depends on ability to eradicate all lesions,¹⁵ and endometriosis is most likely to recur close to the original area of involvement as a result of incomplete excision or ablation.¹⁶ In experienced hands, laparoscopic surgery helps afford long-term symptomatic relief, improves pregnancy rates, and reduces recurrence of disease while largely avoiding complications.¹⁷ Complete excision is essential for improving pain and preventing disease recurrence.¹⁸

Benefits and complications of therapy

With regard to fertility, excisional surgery improves rates of spontaneous pregnancy in the 9 to 12 months after surgery as compared to ablative surgery.¹⁹ Moreover, laparoscopic surgery has been demonstrated to improve rates of live birth and pregnancy compared with diagnostic laparoscopy alone. In contrast, there is no evidence that medical treatment improves clinical pregnancy rates.¹⁹ Although management of endometriomas is controversial, medical therapy may lead to temporary reduction in size but not resolution of cysts. Therefore, surgery is the recommended primary approach for symptomatic and/or large cysts and there are no indications for prescribing medical treatment before cystectomy.²⁰

Gonadotropin-releasing hormone analogs (GnRH-a) and minimally invasive surgery are associated with increased pregnancy rates in women with endometriosis, but GnRH-a, danazol, and depot progestogens are associated with a higher incidence of adverse events.²¹ Lastly, data have been published on damage to ovarian tissue by excision of endometriomas. However, surgery remains the gold standard, provided that it is performed with proper techniques by highly trained surgeons.²² In fact, previous medical treatment of endometriosis or large cyst size may be a significant factor associated with higher rates of disease recurrence.²³

Patients with endometriomas may have decreased ovarian reserve compared with age-matched subjects with other benign ovarian cysts, suggesting that an endometrioma may be harmful to ovarian reserve if left unchecked. With early surgical intervention, that could potentially be avoided, preventing occurrence of endometriomata in the first place.²⁴

Laparoscopic resection can relieve endometriosis-associated symptoms and enhance psychological well-being.²⁵ Complete excision, including vaginal resection, can offer significant improvement in sexual function, quality of life, and pain in symptomatic patients,²⁶ and a well-trained interdisciplinary team can perform laparoscopic treatment of deeply fibrotic endometriosis with a low incidence of major complications.²⁷

In contrast, medical therapy is neither diagnostic nor a long-term treatment option. Counseling patients to undergo a lengthy protocol of suppression serves only to further delay the diagnosis and definitive treatment. GnRH-a administration may be followed by a temporary improvement of pain in patients with incomplete surgical treatment, but it has no role in postsurgical pain when a surgeon is able to completely excise disease.²⁸ Hence, surgery is the diagnostic and gold standard treatment, although indeed results are often operator-dependent.

Subsequently, many patients may benefit from early referral to an endometriosis center of expertise for careful clinical assessment and appropriate investigation in a timely manner.

When properly removed through the excisional technique, endometriosis is far less likely to recur, fertility is preserved, and symptoms are reduced or even eliminated; no medical suppression is needed. When insufficiently treated through incomplete surgery and/or merely temporarily suppressed, however, progressive symptoms will likely continue,²⁹ leading to additional and ongoing surgeries and medical therapies.

Summary

Although all concerned with endometriosis will agree that early intervention and increased, accurate awareness are requisite to reduce morbidity, infertility, and progressive symptomatology, it is clear that failure to timely diagnose and treat has consequence for patients.

We must strive to meet the challenges surrounding endometriosis and encourage improved health literacy, early intervention, and diagnosis combined with the gold standard: excisional treatment. Such an approach will not only improve quality of life for countless patients, but also reduce the significant healthcare costs associated with the disease: nearly $120 billion annually.³⁰

References

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