Surgical Treatments for Endometriosis

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Dr. Togas Tulandi:  “I’m Togas Tulandi and I’m the Professor for Obstetrics and Gynecology at McGill University in Montreal, Quebec, Canada.  Beside me is Dr. David Redwine who is the Director of the Endometriosis Institute of Oregon.  David, you and I have been interested in endometriosis for a long time, what’s the current management of endometriosis in women with infertility?”

Dr. David Redwine:  “Of course, that depends on who you talk to.  There’s a variety of opinions out there ranging from the old reproductive endocrinology opinion that you shouldn’t do anything surgically to endometriosis because you will induce adhesions that can sterilize the patient to medical management, although there is no FDA approved medicine for treatment of infertility associated endometriosis, to extensive surgical removal of all endometriosis by surgeons that are capable of doing that.  Those three main prongs of management are continuing to this day.”

Dr. Togas Tulandi:  “I think there is enough evidence showing that surgical treatment is better for infertile patients because there is no delay in fertility, after surgery they get pregnant.  Let me ask you, what technique is the best to remove this endometriosis at laparoscopy?”

Dr. David Redwine:  “I think if a surgeon believes that endometriosis is causing a symptom, whether it’s infertility or pain, the surgery that results in the most complete removal of the disease should be the best surgery.  In my hands, I found that excision is the thing that works the best.  In the early years of my practice, I remember treating two patients with electrocoagulation and I re-laparoscoped those patients two or three months later and their disease was still present.  It was at that point early in my career that I decided for me the only way that I could treat this disease comfortably was to remove it and make sure it’s all gone.  So I believe that excision is the best way to treat the disease whether it’s superficial or deep.”

Dr. Togas Tulandi:  “Actually, I would agree with you; I have stopped doing coagulation.  I found the same thing like you, at second-look laparoscopy we find endometriosis again, and the risk of adhesions after excision is very small.  Coagulation causes thermal damage as well and might cause adhesions, and I have done many second-look laparoscopies after excision and there are very little adhesions.  In fact, on one we operated on, we stripped the whole peritoneum and I found very little adhesions.”

Dr. David Redwine:  “I think it depends in part on where you operate, if you operate on or around the ovary, I think that that patient is more prone to develop some adhesions than if you do endometrial surgery at the bottom of the pelvis where fortunately the endometriosis is most commonly located anyway.”

Dr. Togas Tulandi:  “Now I think you’re still using unipolar scissors?”

Dr. David Redwine:  “Yes.”

Dr. Togas Tulandi:  “Have you used other techniques – laser or others?”

Dr. David Redwine:  “I have never fired the laser out of the human female pelvis.  I’m probably one of the only gynecologists that might be able to say that at this point.  The only other technique that I’ve used laparoscopically is the two early cases about twenty-one years ago of LF coagulation, which I mentioned.  I formerly used the scissors just in a cold cutting technique but I found that electrosurgical excision is just much easier, faster, and it makes surgery pleasant for me again.”

Dr. Togas Tulandi:  “I’ve used laser and I’ve used electrocoagulation, now I’m using scissors.  I think that the results are the same, and there are several studies showing that the results are the same.  Now how about pelvic pain, David, is your approach the same?”

Dr. David Redwine:  “Pelvic pain is the most common and most specific symptom of endometriosis, and I think that once again if the doctor believes that endometriosis is the cause of pain, the surgery that removes the disease most completely is the best surgery.  So I treat endometriosis the same for any symptom of any age patient, it’s always excision and it’s always aggressive excision.  Now you have to remember though that I’ve operated on over 2,200 patients with endometriosis at this point in my career so I’m quite comfortable doing this.  Excision isn’t something that every surgeon should just jump in and start to do because everybody agrees that it is technically more difficult than laser vaporization or electrocoagulation, but it’s also by the same token much more effective.”

Dr. Togas Tulandi:  “Maybe I should mention that there is a study in Canada looking at infertility in women with mild or minimal endometriosis and treatment could be with laser, electrocoagulation, or excision.  It seems like the results with any technique is better for infertility than no treatment.  But that’s only for minimal and mild endometriosis, we don’t know about more extensive disease.  Let me ask you about post-op medical treatment.”

Dr. David Redwine:  “I don’t, most of the patients who come to see me have had multiple rounds of previous medical therapy and multiple rounds of surgery.  I could not convince my patients to take medical treatment after surgery even if I wanted to or even if I believed in medical treatment, which I don’t.  I also don’t like the patients to use medical therapy after surgery because then that obscures the true effect of surgery.  One of the things that people may not notice when they read a follow-up study that I might produce is that the results that they’re seeing are primarily the results of surgery and not combined surgery followed by medical therapy which frequently can be something that you see with other surgical…”

Dr. Togas Tulandi:  “How about medical therapy before surgery?”

Dr. David Redwine:  “I don’t like to use it before surgery either because Johann Evers showed, I think back in 1988, that if you have somebody on a GnRH agonist that not all the endometriosis is visible at the time of surgery.  If you stop the agonist and wait three months, more endometriosis is visible so that’s one of the things that worries me about the GnRH agonists and doctors thinking that it makes surgery easy.  Does it make it easy because they see less of the disease and so the surgery is more incomplete?  I think that may be what’s going on so I like to see the disease full-blown and stimulated as much by estrogen as possible so that I have every possibility of finding it and removing it.”

Dr. Togas Tulandi:  “I would agree actually.  I don’t use LHRH analogues before surgery; it doesn’t make the surgery easier.  I also don’t use it for a myoma before myomectomy; in fact, it makes the surgery more difficult.  Sometimes there is no surgical plane and there’s more bleeding so I don’t use LHRH.  I might use LHRH analogue post-op for pelvic pain but as you said, it might obscure the result of your surgery.  Let me just close this interview by saying that for some women who are interested in endometriosis there is an Endometriosis Association.  I think they have their own website which they can visit as well.  I’d like to thank Dr. Redwine; David, thank you very much.”

Dr. David Redwine:  “You’re welcome.”