Treatment of endometriosis : surgery
Before Surgery
THE PANDORA BOX OF TREATMENT : Click to read the full text
- the indication is based on symptoms and aided by ultrasound : see diagnosis of endometriosis
- requires correct information and informed consent
Preoperative exams
- No suspicion of deep endometriosis - or severe adhesions: surgery can be planned as day surgery without additional exams.
- deep Endometriosis or severe adhesions are suspected and surgery can be unexpectedly difficult including bowel surgery and suturing of the ureter and the bladder and occasionally a nerve dissection
- IVP or other exams to check for hydronefrosis.
- Contrast enema to ascertain less than 50% sigmoid occlusion over less than 2-3 cm
- Ultrasound may have suspected a bladder nodule
Medical therapy before surgery ?
- medical therapy can be given for a short time to help with the diagnosis
- has no place before surgery
- can be given after surgery if surgery was incomplete ;
During diagnostic laparoscopy
we perform the surgery if needed
During the diagnostic laparoscopy we perform surgery if needed
- only in cases of unexpected severe deep endometriosis of the bowel a bowel resection is perform during a second surgery. This risk is less than 2%
- it should be discussed with the patient which type of intervention they do NOT want eg an ovariectomy
Technical aspects of equipment
- we normally perform surgery with scissors and bipolar, occasionally monopolar electrosurgery
- we do not use ultracision
- we have a CO2 laser
- CO2 laser was frequently used during the pioneering period of endoscopic surgery. Today however the place of CO2 laser surgery is limited to superficial endometriosis or hydrosalpinges
- Contra : The quality of the image is less for technical reasons.
- Pro : Theoretically tissue damage is minimal i.e. of 100 micron only with probably less adhesion formation, as seen below
Surgical treatment of Subtle Endometriosis
- Subtle endometriosis should not be considered a pathology since there is no (proven) association with pain or infertility.
- Since CO2 laser vaporization takes a few seconds; without risks, we prefer to treat.
- Aggressive coagulation of large areas should not be done since not necessary and because of the risk of adhesion
- Common mistake : subtle endometriosis is treated aggressively causing unnecessary adhesions.
Surgical Treatment of Typical Endometriosis
- takes 15 min only
- Typical endometriosis lesionsshould be vaporized or excised. For this the CO2 laser has specific advantages.
- we do not use coagulation only since the depth of invasion cannot be judged superficially.
- for the diaphragm however superficial coagulation is used in order to prevent perforation
Results of surgical treatment
- Fertility : some 50% of women will conceive
- Pain : pain will be less
Surgical treatment of cystic Ovarian endometriosis
Indication for surgical treatment
- All endometriosis cysts larger than 3-4 cm that causes pain
- If IVF is indicated, and the cyst is small it is unclear whether it is preferable to do surgery first
How should surgery be done ?
- If less than 5 cm in Diameter
- Very small lesions can be vaporized.
- A cystic corpus luteum should not be operated.
- The method of choice is excision of cyst since the recurrence rate is 5% only. Superficial coagulation has a recurrence rate of more than 20%. For this reason I stopped vaporization in 1996
- If more than 5 cm in Diameter :
- either a 2 step surgery to preserve the ovary or an adnexectomy should be done since excision will generally cause destruction of the ovary
- The first surgery is a 10 min day surgery with aspiration and rinsing of the endometrioma. After 3 months of GNRH therapy the cyst has become small and can be excised
Complications of surgery :
if not done carefully or without the necessary training
- Ovarian damage and a decreased ovarian reserve
- Only video-registration can demonstrate that a plane was missed, or that excessive coagulation, especially of the hilus damaged the blood supply.
- Surgery for ovarian cysts is erroneously considered ‘easy’. Reality is that many women will have a decreased ovarian reserve after surgery, whereas reports from excellent surgical groups do not show any decrease. Surgery for cystic ovarian endometriosis therefore is delicate, with superficial coagulation of bleeding vessels only.
- Since coagulation is done minimally , this carries the risk of some 3-4 % haematoma’s after surgery.
Results of surgery
- Recurrence rate of 5%
- Pain : disappears in over 90%
- Fertility : 70% spontaneous pregnancy rate within 1 year
Deep endometriosis is difficult surgery
Types of deep endometriosis
We were the first to describe deep endometriosis and its excision back in 1989
Surgically 4 Localizations and types should be distinguished
- Recto-vaginal
- Sigmoid
- Bladder
- ureter
- rare presentation : ovarian remnant
We performed over 2500 deep endometriosis resections in Leuven, some 300 in Oxford and some 250 in Rome
What is the problem of Deep endometriosis Surgery
- It can be technically very demanding surgery because of distorted anatomy and occasionally surgery of the bowel, the ureter, and the bladder.
- difficulty increeases exponentially with size.
- Therefore this surgery needs a thorough preoperative preparation.
- Occasionally a deep endometriosis can be an unsuspected finding. In this rare case it is important not to operate because of the absence of a bowel preparation.
- This surgery requires a surgeon with the necessary expertise, the right equipment, and a good team (assistant, nurses) to have adequate assistance to deal with any problem of bowel, bladder, or ureter during surgery.
- Also close supervision during the postoperative period is equally important .
Deep endometriosis of the sigmoid
- A contrast enema is the best diagnostic method to diagnose sigmoid endometriosis and to judge the degree of bowel stenosis.
- If the stenosis is less than 50% over less than 2-3 cm we try a discoid resection. I the stenosis is more than 50% over more than 2-3 cm we do an elective sigmoid resection is performed
- Sigmoid endometriosis almost always is invasive. in 90% invasion of the muscularis , in more than 50% transmural
- over the years we became more liberal to do a sigmoid resection because of the much lower complication rate for a sigmoid resection. In addition a discoid resection of the sigmoid is technically very difficult surgery and should be avoided unless very experienced.
Deep endometriosis : recto-vaginal and rectosigmoid
- In our experience complete discoid excision is almost always possible since we only performed a low bowel resection in 3/2000 women. For a more thorough discussion on bowel resections see a recent systematic review discussing this
- When bigger than 3 cm and when fixed to the spine a lot of experience is necessary.
- Excision should be complete but a rim of fibrosis can be left
- Deep Endometriosis invades the muscle of the bowel in 50% whereas 20% are transmural. Complete resection of deep endometriosis thus requires a muscularis resection with one layer suture in some 50% and/or a full thickness resection in some 20% with a double layer suture.
- care is aken not to damage the parasympaticus nerve because of the risk of temporary bladder retention
- A low bowel resection should be avoided because of the high complication rate, the 30% live long bowel, 30% bladder and 40% sexual problems. Moreover there is no demonstrated advantage
Deep endometriosis : Bladder
Diagnosis should be suspected clinically but sometimes an experienced ultrasonographist can make the diagnosis If the lesion is big, it is wise to do a cystoscopy to check the position of the ureters. In doubt we insert a double J stent in the ureter Excision can be radical without hesitation since the bladder heals well The bladder is my friend since she heals well
Deep endometriosis : Ureter involvement and ureter surgery
- Deep endometriosis surgery can involve the ureter and cause hydronefrosis.
- Although rather frequent for larger lesions this can even occur in smaller deep endometriosis.
- Therefore the surgeon should know beforehand whether ureter surgery can be anticipated and he should have the skills to do so.
- If hydronefrosis : a preoperative stent is mandatory since associated with an 18% risk for ureter lesion
- If no hydronefrosis : a systematic stent is over-treatment and should not be used. First it is not necessary (risk of lesion less than 0.5%), second it causes pain and fibrosis .Most importantly all ureter lesions can be treated by laparoscopy with excellent outcome as we demonstrated in 2 recent reviews a review of the literature in 2007 and personal data 2009
The small hole hides a big defect. This is easily missed if not experienced
Deep endometriosis : ovarian remnant Syndrome
- This is a rare pathology and missed unless experienced
- the ureter is always at the middle of the ovary
- always very difficult surgery
Peritoneal Pockets
- Peritoneal pockets are not that well known and often not easy to diagnose.
- Generally an endometriosis spider is present.
- As shown in the image the small hole hides a big defect. This is easily missed if not experienced .
- Excision is the therapy of choice. When infiltrating up to the nerves this can be technically challenging
Deep endometriosis : Complications and Postoperative management
Deep endometriosis surgery requires experience and a team Not only the surgeon should be experienced, but also the assistant, and preferentially the second assistant, as occurs in the Gruppo Italo Belga. This permits to discuss during surgery when in doubt. Such a team know the following rules
Complete surgery is necessary. Incomplete surgery is a serious complication. The surgery not only will have to be repeated, but most importantly the second surgery will be more difficult. Sometimes it is a difficult decision when the lesion is not very clear : without experience the surgeon will refrain because of the risk of bowel perforation, and thus will leave endometriosis behind.
- complete excision is especially important at the level of the vagina since this is the most frequent localisation of recurrences
- a layer of fibrosis can be left on the bowel.
- that the bladder heals well and that surgery thus can be radical.
- all ureter lesions can be treated by laparoscopy and that a re-implantation of the ureter no longer is the first line treatment
- unnecessary bowel resections should be avoided : indeed in some series up to 14% of women with a bowel resection for endometriosis did not have endometriosis
- the risk that of an accidental hysterectomy is zero
- the risk of an accidental ovariecomy also is non-existent
- hydronefrosis is associated with a risk of 18% ureter lesions ; with a normal ureter this risk is less than 0.5%.
- a 2cm nodule in the rectum carries a risk of a muscularis resection and a 1 layer suture of 50% ; for the sigmoid the risk would be 90%
- a 3 cm nodule is associated with a full thickness resection en a double suture of 40 and 95% respectively.
Other potential complications and fatigue Complications are those of severe surgery and the risk is mainly dependent on the expertise of the surgeon and his team. We published as recognizable risk factors an inexperienced assistant, inadequate equipment, and fatigue. Clearly all 3 factors relate to the duration of surgery. As a rule of thumb I consider that for surgeons get tired after 5 hours and that attention and precision decreases.
POSTOPERATIVE MANAGEMENT.
- a 1 layer prophylactic suture requires an hospitalization of 4 days; a double layer suture requires an hospitalization of 7 days.
- an hydronefrosis with ureter wall resection and suture requires a double J stent for 6 weeks.
- a bladder deep endometriosis with a full thickness bladder wall resection, and suture requires a bladder catheter for 7 days.
- Risk management and video-registration Since video-registration of entire procedures is systematically used we do analyse each complication of surgery.
- most important is the experience of the team taking care postoperatively in order to recognise immediately complications
POSTOPERATIVE COMPLICATIONS
- A late bowel perforation occurred in some 5% - since we introduced massive lavage this risk has fallen below 0.5% We recognized and published this as early as 1996 This complication is severe and requires a close supervision of the patient for 5 days since the symptoms are vague and since a late perforation is easily missed if not experienced. The importance of immediate recognition is that a late perforation can be treated by a repeat laparoscopy and a suture of the perforation. If however the perforation exists for more than 24 hours a colostomy is necessary because of a 4 quadrant peritonitis
- 1-2% recto-vaginal fistulas In order to avoid this we prefer not to associate an hysterectomy with surgery of deep endometriosis
- Bleeding and infection
- Bladder retention occurs in some 10-15 % especially in big nodules with lateral extension. This complication rarely last longer than 3 months.
- Provided early repeat laparoscopy all complications can be managed by laparoscopy.
Results of endometriosis surgery
- Subtle endometriosis
- No effect upon pain or infertility since it is not a cause of pain nor of infertility.
- Endometriosis surgery is probably not useful and will not prevent recurrences.
- Since, endometriosis surgery takes a few minutes without risks, superficial vaporization with a CO2 laser is performed
- Typical endometriosis
- Pain : After excision , a significant reduction in pain occurs in 50% of the women only as demonstrated in the RCT of Sutton.
- infertility : Endometriosis surgery is believed to increase fertility rate during 6-12 months. The data however are not clear.
- Recurrences : 20% over 10 years.
- Cystic ovarian endometriosis
- pain severe pain will decrease by 90%
- infertility the cumulative fertility should be around 60% after 12 months.
- Recurrences : less than 5% after complete excision.
- The biggest risk is (partial) destruction of the ovary. This occurs rather frequently if the surgeon is not sufficiently experienced. Therefore quality control should be introduced
- Deep endometriosis
- Pain Endometriosis surgery will cure pain in over 85%. In the remaining 15% the difficult question whether surgery was incomplete cannot be answered without video-registration
- infertility is still unclear whether deep endometriosis causes infertility, since some 50% of the women with deep endometriosis have children. Anyway the cumulative fertility should be around 60% after 12 months
- Recurrences is some 1% if completely excised. There is no advantage when a bowel resection is performed
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