Surgical treatment of endometriosis

Our plain-English summary of Surgical treatment of endometriosis, by F.M. Howard (Obstetrics and Gynecology Clinics of North America, 2011).

The study

• Author: F.M. Howard
• Journal: Obstetrics and Gynecology Clinics of North America
• Published: 2011;38(4):677-86
• Type of article: Review
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

In this review, the pitfalls that still exist with the surgical treatment of endometriosisassociatedpelvic pain have been discussed and the best evidence regarding various aspects of surgical techniques have been reviewed. When laparoscopy is performed to evaluate a woman with pelvic pain symptoms, it is important she be counseled that the primary function of the surgery is to confirm the presence (and allow surgical treatment) of endometriosis, and that it is not the penultimate diagnostic modality for her pelvic pain. There are many etiologies of pelvic pain that present with symptoms resembling those of endometriosis-associated pelvic pain that are not diagnosable with laparoscopy, such as interstitial cystitis and irritable bowel syndrome. It is unfortunate that many women are left with the belief that if a laparoscopy fails to provide a diagnosis of a pain generator, then it means there are no diagnoses other than that the “pain is in her head,” often disparagingly termed “supratentorial” byclinicians. In fact, the pain-related diagnoses that are amenable to and possibly require a laparoscopy are quite limited, a group of diagnoses that this author terms the “dirty dozen” because there are just 12, and only the first 4 have good evidence to clearly associate them with chronic pelvic pain:1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic)9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian.I would argue that diagnostic laparoscopy in modern gynecology has a limited, if any role, and that when laparoscopy is planned for women with chronic pelvic pain, it should be with a very high suspicion of a diagnosis and with plans to treat the disease operatively. In this era, a negative diagnostic laparoscopy should be a rare event.

In plain English

This article reviewed surgical treatment of endometriosis-associated pelvic pain; its author was from a university obstetrics and gynecology department in Rochester, New York. Endometriosis is tissue resembling the lining of the uterus found outside the uterine cavity. The article did not study asbestos. The author described pitfalls in surgery. Endometriosis found during an operation may not be what causes a woman's pain, and diagnosing it by appearance alone was unreliable: the best data cited gave a visual diagnosis only a 45% positive predictive value. Neither of two randomized trials comparing excision with ablation found a difference in pelvic pain relief, although studies of endometriomas showed recurrence was less likely after excision. Four randomized trials showed that a nerve-cutting procedure called laparoscopic uterine nerve ablation had no role. Medicines given after surgery lowered pain only while they were being taken. The author listed 12 diagnoses that may call for laparoscopy and said only the first four had good evidence linking them to chronic pelvic pain. Benign cystic mesothelioma was sixth on the list. The author argued that diagnostic laparoscopy had a limited role, if any.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: narrative review of published evidence on surgical treatment of endometriosis-associated pelvic pain
• Who was studied: No new study population; the review covered published studies of women with endometriosis-associated pelvic pain (infertility treatment excluded)
• Main results:
  • The review cited data indicating that a visual diagnosis of endometriosis at laparoscopy has only a 45% positive predictive value
  • The author reported data from the author's own pelvic pain center, from a separately published study. Only 18% of women with endometriosis had endometriosis as their only pain-related diagnosis. 31% also had irritable bowel syndrome and 32% also had interstitial cystitis/painful bladder syndrome.
  • Neither of two randomized trials comparing excision with ablation was able to show a difference in relief of pelvic pain between the two techniques
  • For endometriomas, at least 4 studies taken together showed recurrence was less likely with excision than with ablation or coagulation
  • The author stated that four randomized trials show laparoscopic uterine nerve ablation (LUNA) has no role in treating pelvic pain or endometriosis-associated pelvic pain
  • Two trials of presacral neurectomy for endometriosis-associated dysmenorrhea were combined. Together they gave an odds ratio for efficacy of 3.1 (95% confidence interval, 1.6 to 6.2) and a number needed to treat of 4.5.
  • In the trials reviewed, medical treatments after surgery decreased pain more than surgery alone, but only while the medications were continued
  • Benign cystic mesothelioma was listed sixth among the 12 pain-related diagnoses the author considers amenable to laparoscopy. The author stated only the first 4 have good evidence associating them with chronic pelvic pain.
• The authors' conclusion: The author argued that diagnostic laparoscopy has a limited role, if any, in modern gynecology. Laparoscopy for chronic pelvic pain should be planned with high suspicion of a diagnosis and plans to treat it, and a negative diagnostic laparoscopy should be rare.
• Limitations the authors state:
  • The author noted limited published evidence on preoperative medical treatment
  • The author noted there are no well-designed clinical trials on the efficacy of the various extirpative (organ-removing) surgical options

Topics

Medical terms in this study, explained in our Lexicon: Interstitial, Mesothelioma, Diagnostic Laparoscopy.

Related studies

• Laparoscopic management of peritoneal mesothelioma associated with pelvic endometriosis — F.R. Nezhat, S.M. DeNoble, et al. (2010)
• Peritoneal mesothelial hyperplasia associated with gynaecological disease: a potential diagnostic pitfall that is commonly associated with endometriosis — R. Oparka, W.G. McCluggage, et al. (2011)
• Multicystic mesothelioma with endometriosis — G.M. Groisman, H. Kerner (1992)
• Multicystic mesothelioma caused by endometriosis: 2 case reports and review of the literature — Y. Kurisu, M. Tsuji, et al. (2011)
• Malignant peritoneal mesothelioma in patients with endometriosis — K.J. Butnor, J. Rueckert, et al. (2018)
• An incidental diagnosis of well-differentiated papillary mesothelioma in a woman operated on for recurrent endometriosis — R. Mangal, O. Taskin, et al. (1995)

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