Surgical incision or ablation for endometriosis-related pain?

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Kristin Riley, MD

VAS Scores

When it comes to improving symptoms of chronic pelvic pain in women with minimal to mild endometriosis who undergo laparoscopy, ablation appears to beat surgical incision, at least in the short term, according to a randomized controlled trial in The Journal of Minimally Invasive Gynecology.

“Our main outcome was visual analog scale (VAS) scores for dysmenorrhea, dyschezia, dyspareunia and nonmenstrual pain,” said primary author Kristin Riley, MD, director of fellowship research at Virginia Mason Medical Center in Seattle, Washington. “There were no significant changes in VAS scores at 6 and 12 months after excision.”

In contrast, there was a 14.07% mean improvement in dyspareunia VAS scores in the ablation group at 6 months. “However, this improvement was not maintained at 12 months,” Dr. Riley told Contemporary OB/GYN. Still, for ablation, there was a 26.99% mean reduction in dysmenorrhea VAS scores at 6 months and a 24.15% reduction at 12 months.

“Overall, when comparing the change in VAS scores between the two groups, there was a greater reduction in dyspareunia at 6 months in the ablation group compared with the excision group,” Dr. Riley said. “But this difference was lost at 12 months.”

The investigators were inspired to undertake this study due to the small number of prospective randomized studies evaluating excision and ablation of endometriosis for superficial endometriosis. “Prior to our study, there were only two other randomized clinical studies comparing excision versus ablation of endometriosis,” Dr. Riley said. “We wanted to shed light on the continuing debate over whether excision or ablation results in more symptomatic improvement.”

The study was carried out at the Penn State Hershey Medical Center, which is an academic tertiary-care hospital. Between December 2013 and October 2014, 73 patients were randomized intraoperatively to either excision (n = 37) or ablation (n= 36) of endometriosis using robotic-assisted laparoscopy. 

Patients evaluated their symptoms at baseline, 6 months, and 12 months. Secondary outcomes included survey results at baseline and 6 and 12 months from the 36-item Short Form Health Survey (SF-36) 

In the ablation group, there was a 7.14% mean improvement in the Physical Component score of the SF-36 at 6 months and a 9.20% improvement at 12 months, whereas in the excision group, there was only a 5.22% improvement at 6 months which did not extend to 12 months. But there were no dramatic changes in the Mental Component score of the SF-36 for either group.

Likewise, responses to the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) showed no statistically significant changes in either group. Patient responses on the International Pelvic Pain Assessment Questionnaire indicated that there were more statistically significantly improved parameters in the ablation group.

The investigators expected better results for the excision group. Although the reason for the outcomes in that group is unclear, “we hypothesize that there may be less damage to surrounding normal tissue with ablation,” Dr. Riley said.

Based on study results, though, she is reluctant to endorse ablation over surgical excision in this patient population. “Instead, we recommend an individualized approach for patients with endometriosis, including surgical decisions predicated on the location and type of endometriosis found at the time of laparoscopy,” she said.

Dr. Riley also noted that careful patient counseling about expectations for surgical intervention is key to successfully managing the disorder long term.

Disclosures:

Dr. Riley reports no relevant financial disclosures.