Endometriosis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Joseph Nasr, M.D.[2], Aravind Kuchkuntla, M.B.B.S[3]
Overview
Surgery is not the first-line treatment option for patients with endometriosis. Surgery is usually reserved for patients with failed medical therapy and patients with stage 3 or stage 4 disease.
Current guidelines recommend surgical management for patients with persistent pain despite appropriate hormonal therapy or when hormonal therapy is contraindicated or not tolerated.[1][2]
Surgical intervention should also be considered in patients with deep endometriosis causing hematuria, hematochezia, or obstructive conditions of the urinary or gastrointestinal tract.[3][4]
Ovarian endometriomas larger than 5 cm or those with imaging features concerning for malignancy may warrant surgical management due to low likelihood of resolution with hormonal therapy.[5]
Surgery
Surgical therapy for endometriosis can be classified as conservative or definitive based on the presentation of the patient.[6]
Histologic confirmation of endometriosis obtained during laparoscopy remains the criterion standard for diagnosis.[7]
Most surgical management is performed laparoscopically, and complex cases involving bowel, ureter, or thoracic structures may require a multidisciplinary surgical approach.[8]
Conservative therapy:
- Conservative therapy is preferred in young women who desire to get pregnant and in patients with no improvement of pain after pharmacological treatment.
- Surgery includes removal of the endometrial lesions with excision and destruction of the lesion by laser or electrocautery. Evidence supporting surgical excision for superficial peritoneal disease is limited, and there is insufficient high-quality evidence comparing excision versus ablation techniques; choice of technique often depends on surgeon preference.[9][10]
- Laparoscopic uterosacral nerve ablation or laparoscopic pre sacral neurectomy can be done for chronic pelvic pain.[11]
Ovarian Endometriomas
- For ovarian endometriomas, cystectomy is associated with lower recurrence and improved pain outcomes compared with drainage and ablation.[12]
- In a Cochrane review of 9 randomized trials (n = 578), cystectomy reduced dysmenorrhea (19.5% vs 49.3%; P < .001) and reduced cyst recurrence (9.1% vs 36.9%; P < .001) compared with drainage and ablation.[12]
- However, cystectomy may negatively affect ovarian reserve. A meta-analysis of 8 studies (n = 237) reported a 38% reduction in postoperative anti-Müllerian hormone levels following cystectomy.[13]
Deep Endometriosis
- For deep endometriosis, laparoscopic excision may reduce pain and improve quality of life.[8]
- In a large multicenter prospective cohort study (n = 4721), laparoscopic excision of deep rectovaginal endometriosis was associated with significant reductions in menstrual pain, noncyclical pelvic pain, dyspareunia, and dyschezia at 24 months (all P < .001).[14][15]
- Complications occurred in approximately 7% of patients, with hemorrhage and conversion to laparotomy occurring in less than 1%.[15]
- Resection near or involving the ureter, bowel, or thorax carries increased risk and should involve interdisciplinary surgical care.[8]
Postoperative Management
- Postoperative hormonal suppression is associated with reduced recurrence and improved pain outcomes.
- In a meta-analysis of 11 randomized trials and 3 prospective cohort studies (n = 1766), postoperative hormonal suppression reduced recurrence (10.7% vs 26.4%; RR 0.41, 95% CI 0.26–0.65).[16]
- A separate meta-analysis (6 randomized trials and 1 prospective cohort study; n = 652) demonstrated reduced pain scores with postoperative suppression (standard mean difference −0.49; 95% CI −0.91 to −0.07).[16]
Limitations of Surgery
- Persistent pain may occur despite surgical excision of lesions.
- In a systematic review of studies evaluating surgery without postoperative hormonal therapy (n = 2652), persistent pain occurred in 25% of patients and adverse events occurred in 8.1% at median follow-up of 24 months.[17]
- Pain recurrence may occur even without visible recurrent lesions, suggesting contributions from central sensitization mechanisms.[18]
- Repeated surgeries should be avoided when possible due to limited high-quality evidence demonstrating long-term benefit.[19]
Definitive surgery:
- Guidelines recommend considering hysterectomy for patients with persistent pain who do not desire future fertility and who have failed medical and conservative surgical management.[5]
- Quality of evidence supporting hysterectomy for pain control is limited due to lack of randomized trials and short follow-up duration.[20]
- A retrospective cohort study (n = 4489) reported a 10.5% reoperation rate within 10 years following hysterectomy for endometriosis.[21]
- Nearly 50% of patients undergoing hysterectomy for recurrent pelvic pain do not demonstrate recurrent endometriosis lesions.[18]
- When ovaries appear normal and there is no known genetic risk of ovarian cancer, ovarian conservation is generally preferred to avoid risks associated with surgical menopause.[22][23]
- Patients should be counseled regarding potential long-term risks of hysterectomy, including cardiovascular, metabolic, and mental health disorders.[24][25]
Fertility Considerations
- Surgical removal of endometriosis lesions solely to improve outcomes prior to assisted reproductive technology is not recommended due to unclear benefit.[26]
- Assisted reproductive technologies such as in vitro fertilization may be used in patients with endometriosis-associated infertility.[26][27]
References
- ↑ Practice bulletin No. 114: management of endometriosis. Obstet Gynecol. 2010;116(1):223-236. doi:10.1097/AOG.0b013e3181e8b073
- ↑ Leyland N, Casper R, Laberge P, Singh SS; SOGC. Endometriosis: diagnosis and management. J Obstet Gynaecol Can. 2010;32(7)(suppl 2):S1-S32. doi:10.1016/S1701-2163(16)34589-3
- ↑ Horne AW, Missmer SA. Pathophysiology, diagnosis, and management of endometriosis. BMJ. 2022;379:e070750. doi:10.1136/bmj-2022-070750
- ↑ Leonardi M, Gibbons T, Armour M, et al. When to do surgery and when not to do surgery for endometriosis: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2020;27 (2):390-407.e3. doi:10.1016/j.jmig.2019.10.014
- ↑ 5.0 5.1 Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Australian Clinical Practice Guideline for the Diagnosis and Management of Endometriosis. Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 2021. Accessed February 10, 2025. https://ranzcog.edu.au/wp-content/uploads/+2022/02/Endometriosis-clinical-practice-guideline.+pdf
- ↑ Singh SS, Suen MW (2017). "Surgery for endometriosis: beyond medical therapies". Fertil Steril. 107 (3): 549–554. doi:10.1016/j.fertnstert.2017.01.001. PMID 28189295.
- ↑ Singh SS, Allaire C, Al-Nourhji O, et al. Guideline No. 449: diagnosis and impact of endometriosis—a canadian guideline. J Obstet Gynaecol Can. 2024; 46(5):102450. doi:10.1016/j.jogc.2024.102450
- ↑ 8.0 8.1 8.2 Becker CM, Bokor A, Heikinheimo O, et al; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022; 2022(2):hoac009. doi:10.1093/hropen/hoac009
- ↑ Bafort C, Beebeejaun Y, Tomassetti C, Bosteels J, Duffy JM. Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev. 2020; 10(10):CD011031.
- ↑ Burks C, LeeM, DeSarno M, Findley J, Flyckt R. Excision versus ablation for management of minimal to mild endometriosis: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2021; 28(3):587-597. doi:10.1016/j.jmig.2020.11.028
- ↑ Api M (2015). "Surgery for endometriosis-related pain". Womens Health (Lond). 11 (5): 665–9. doi:10.2217/whe.15.52. PMID 26441217.
- ↑ 12.0 12.1 Kalra R, McDonnell R, Stewart F, Hart RJ, Hickey M, Farquhar C. Excisional surgery versus ablative surgery for ovarian endometrioma. Cochrane Database Syst Rev. 2024;11(11):CD004992.
- ↑ Raffi F,Metwally M, Am S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012;97(9):3146-3154. doi:10.1210/jc.2012-1558
- ↑ Byrne D, Curnow T, Smith P, Cutner A, Saridogan E, Clark TJ; BSGE Endometriosis Centres. Laparoscopic excision of deep rectovaginal endometriosis in BSGE endometriosis centres: a multicentre prospective cohort study. BMJ Open. 2018;8(4):e018924. doi:10.1136/bmjopen-2017- 018924
- ↑ 15.0 15.1 Wickström K, Edelstam G. Minimal clinically important difference for pain on the VAS scale and the relation to quality of life in women with endometriosis. Sex Reprod Healthc. 2017;13:35-40. doi:10.1016/j.srhc.2017.05.004
- ↑ 16.0 16.1 Zakhari A, Delpero E, McKeown S, Tomlinson G, Bougie O, Murji A. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Hum Reprod Update. 2021;27(1):96-107. doi:10.1093/humupd/ dmaa033
- ↑ Singh SS, Gude K, Perdeaux E, GattrellWT, Becker CM. Surgical outcomes in patients with endometriosis: a systematic review. J Obstet Gynaecol Can. 2020;42(7):881-888.e11. doi:10.1016/j.jogc.2019.08.004
- ↑ 18.0 18.1 Mowers EL, Lim CS, Skinner B, et al. Prevalence of endometriosis during abdominal or laparoscopic hysterectomy for chronic pelvic pain. Obstet Gynecol. 2016;127(6):1045-1053. doi:10.1097/AOG. 0000000000001422
- ↑ Fang QY, Campbell N, Mooney SS, Holdsworth-Carson SJ, Tyson K. Evidence for the role of multidisciplinary team care in people with pelvic pain and endometriosis: a systematic review. Aust N Z J Obstet Gynaecol. 2023;64(3):181-192. doi:10.1111/ajo.13755
- ↑ Lewin J, Vashisht A, Hirsch M, Al-Wattar BH, Saridogan E. Comparing the treatment of endometriosis-related pain by excision of endometriosis or hysterectomy: a multicentre prospective cohort study. BJOG. 2024;131(13):1793- 1804. doi:10.1111/1471-0528.17910
- ↑ Long AJ, Kaur P, Lukey A, et al. Reoperation and pain-related outcomes after hysterectomy for endometriosis by oophorectomy status. Am J Obstet Gynecol. 2023;228(1):57.e1-57.e18. doi:10. 1016/j.ajog.2022.08.044
- ↑ Kvaskoff M, Horne AW, Missmer SA. Informing women with endometriosis about ovarian cancer risk. Lancet. 2017;390(10111):2433-2434. doi:10. 1016/S0140-6736(17)33049-0
- ↑ Stewart EA, Missmer SA, RoccaWA.Moving beyond reflexive and prophylactic gynecologic surgery. Mayo Clin Proc. 2021;96(2):291-294. doi: 10.1016/j.mayocp.2020.05.012
- ↑ Honigberg MC, Zekavat SM, Aragam K, et al. Association of premature natural and surgical menopause with incident cardiovascular disease. JAMA. 2019;322(24):2411-2421. doi:10.1001/jama. 2019.19191
- ↑ Laughlin-Tommaso SK, Khan Z,Weaver AL, Smith CY, RoccaWA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study. Menopause. 2018;25(5):483-492. doi:10.1097/GME. 0000000000001043
- ↑ 26.0 26.1 Hamdan M, Omar SZ, Dunselman G, Cheong Y. Influence of endometriosis on assisted reproductive technology outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2015;125 (1):79-88. doi:10.1097/AOG.0000000000000592
- ↑ Harb HM, Gallos ID, Chu J, Harb M, Coomarasamy A. The effect of endometriosis on in vitro fertilisation outcome: a systematic review and meta-analysis. BJOG. 2013;120(11):1308-1320. doi:10.1111/1471-0528.12366