Endometriosis: the pros and pros of surgical excision
I am frequently asked how I surgically treat endometriosis and to make a long story short: I excise.
Now the details. It is important to point out that surgery is only part of a successful management plan for endometriosis. While we often find significant improvement in symptoms after surgery it is wise to have a plan for care after surgery.
When discussing operative management with conservation of fertility the goal for most patients is to normalize the anatomy for possible future pregnancy and to relieve painful periods and non-menstrual pain. In order to achieve these outcomes a surgeon must be intimately familiar with normal anatomy, confident in their surgical skills and have a full understanding of the patient’s desires. After obtaining a history, imaging studies and a pelvic exam a physician will hopefully be able to provide a discussion about the potential outcomes of surgery.
Setting expectations for outcomes is an important part of the conversation and can vary extensively in different patients with endometriosis. The first component is to discuss what will be completed at the time of surgery and how it will be done. The goal with surgical excision of endometriosis is to destroy the endometriosis cells. This can be done by burning them (ablation) or removing them (excision).
Excision is technically more difficult because it includes dissecting important pelvic structures (including ureters, blood vessels, bowel) away from the disease and removing the diseased implants of endometriosis. Excision does allow a surgeon to see how deep the implant actually is in the body and to remove as much as can safely be done. Alternatively ablation means that electricity or radio frequency is used to denature the endometriosis cells. While this may treat some of the cells it is difficulty to know how much of the implant is destroyed.
The ability of high quality studies to assess the difference between excision and ablation is limited by a number of factors. At least one article has found that both methods improve pain at 6 and 12 months but that excision has improved outcomes in painful intercourse at 5 years [1]. Another recent study has shown that laparoscopic excision can reduce pain and the effect can persist up to almost 7 years [2].
My experience with hundreds (if not thousands) of woman has convinced me that strong medical and surgical planning, a full understanding of patient goals and excision of endometriosis can provide significant improvement in patients symptoms and improve their quality of life.
https://pubmed.ncbi.nlm.nih.gov/24768960/
https://www.jmig.org/article/S1553-4650(20)30166-7/fulltext