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How is endometriosis treated with surgery?
Endometriosis in its early stages can be treated at the time of diagnosis. Endometriosis
is diagnosed using a surgical procedure called laparoscopy. During laparoscopy, a thin
viewing tube (called a laparoscope) is passed through a small incision in the abdomen. A
second incision may be made on the lower abdomen to provide an additional opening for
surgical instruments.
Using the laparoscope, your doctor can look directly at the outside of the uterus,
ovaries, fallopian tubes and nearby organs. The laparoscope can also be fitted with
surgical devices for taking tissue samples or removing scar tissue.
Endometrial lesions (implants of endometrial tissue outside of the endometrium) can be
cut away (excised) or burned away using a high-energy heat source, such as a laser
(ablation). Treatment with laparoscopy is more difficult with advanced disease that
involves large areas of the rectum or larger lesions.
Does laparoscopic treatment improve fertility?
Treating early stage endometriosis to improve fertility is very controversial. Previous
studies suggest that laparoscopic surgery is effective in increasing the incidence of
pregnancy. A recent study by the Canadian Collaborative Group on Endometriosis
demonstrates that using laparoscopy to remove diseased tissue in minimal and mild
endometriosis enhances fecundity (fertility) in infertile women.
Patients in this study were recruited from a large number of Canadian health care
centers. There were 348 patients who had no other cause of infertility and Stage I and II
disease (early stages). Each patient in the study was randomly assigned to one of two
groups: treatment by laparoscopy or no treatment by laparoscopy. The patients were then
followed for 36 weeks and did not receive further treatment for fertility.
Cumulative probability of pregnancy with the treated group was 30 percent compared
with 17 percent in the untreated group. The fertility rates for the treated
group were 4.7 percent versus 2.4 percent for the untreated group.
Studies have not shown if excision of endometriosis is better than ablation with
different energy sources. A significant number of patients with endometriosis and
infertility have deep lesions (more than 10 millimeters, or 0.4 inches), especially if
associated with pelvic pain. Coagulation (forcing blood vessels to clot) or laser
vaporization is not recommended for patients with lesions deeper than 5 millimeters.
What is an endometrioma?
An endometrioma is a mass of tissue (noncancerous cyst or tumor) that contains shreds of
endometrial tissue. Endometriomas most frequently occur in the ovary, in a part of the
peritoneum (sac around the internal organs) between the rectum and uterus, the wall
(septum) between the rectum and vagina, and the outside of the uterus.
How are endometriomas treated?
Several surgical treatments are available for endometriomas:
- Simple puncture - This procedure is completed by draining the fluid from the cyst.
Endometriomas have been shown to recur in about 50 percent of the patients treated with
simple puncture. However, a more aggressive surgical approach, such as cutting away the
mass, can cause extensive adhesions (scar tissue) that may prevent the ovary from
releasing an egg.
- Ablation - Another approach is to drain the cyst and remove its base with laser or
electrosurgery. However, heat can also damage the ovary.
- Cutting away of the cyst wall - This is the procedure of choice to
decrease recurrence of disease. This procedure can also damage the outer
layer of the ovary that contains the eggs.
- Draining, drug therapy, and surgery - Endometriomas can also be drained, treated
with medication, and later removed by surgery. Endometriomas recur in 8 percent of the
patients treated with this procedure. Results from several different prospective studies
have reported pregnancy rates of 50 percent over 3 years. There are no randomized
clinical trials comparing these different treatment methods.
How is advanced endometriosis treated?
The most challenging surgery by laparoscopy or by laparotomy (traditional abdominal
surgery, which requires a larger incision) is the management of advanced endometriosis
within the pelvic cavity and the rectum and vagina. Several studies have reported
pregnancy rates over 2 years of 50 to 60 percent of cases treated with surgery.
According to several reports, endometriosis may recur in 20 percent of the cases.
Is laparoscopy more effective than laparotomy?
Laparoscopy and laparotomy are equally effective in relieving pain and improving
fertility. Endometriosis recurs in about 20 percent of cases over 5 years in both
procedures. Patients who undergo laparoscopy, however, experience a more rapid and less
painful recovery. Deciding which surgical procedure to use should be based on the
patient's preference and the physician's experience with the technique.
What can be done to reduce the likelihood that new adhesions
will form?
Adhesions are fibrous bands connecting structures that normally are separate.
Adhesions develop as a response of normal tissue to some type of injury or
trauma (as in surgery). In most cases, patients who undergo surgery for
endometriosis will form new adhesions at the site of the surgery. Adhesion
formation may cause infertility by impairing the function of the ovaries and
fallopian tubes. Adhesions also may cause pelvic pain and small bowel
obstruction.
There are some newer preventive treatments that can be used
during surgery to help prevent adhesions from forming. These include rinsing the
pelvic cavity with special solutions and placing a piece of protective material
(such as Interceed) into the pelvic area to serve as a barrier. The barrier keeps
the surfaces from rubbing together after surgery, which can lead to adhesion
formation. The barrier dissolves and is absorbed when it is no longer needed.
In some cases, a woman will have to undergo additional
surgery to remove adhesions formed from previous surgery. Fortunately, the
advancement of laparoscopic surgery and the development of these new preventive
treatments can reduce the chances of adhesion formation.
What is the outlook for treatment of endometriosis?
While many women find success with the current treatments for endometriosis,
medication and surgery do have side effects and don’t work for everyone.
Researchers are continuing to investigate new and improved treatment strategies.
One area of study is focusing on the role of the immune system in the
development of endometriosis, and enhanced hormonal agents are being studied as
a possible treatment option.
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