Laparoscopic management of ovarian endometriomas: a critical review of current practice

Impact of haemostasis methods during ovarian cystectomy on ovarian reserve: a pairwise and network meta-analysis

BACKGROUND

Haemostasis during ovarian cystectomy is reported to damage the ovarian reserve, but the comparative impacts of three haemostasis methods (bipolar energy, suture and haemostatic sealant) on ovarian reserve in patients with ovarian cysts are not well known.

METHODS

The Cochrane Library, PubMed and Web of Science databases were searched from the date of inception of the database to June 2022 for literature exploring the impact of haemostasis methods during ovarian cystectomy on ovarian reserve. A traditional meta-analysis was performed using Review Manager software. A network meta-analysis (NMA) was performed using Stata and GemTC software.

RESULTS

The direct meta-analysis comparison indicated that the mean postoperative reduction of anti-Müllerian hormone (AMH) level was significantly higher in the electrocoagulation (bipolar) group than suture and haemostatic sealant group, both in the overall group and subgroup of women with ovarian endometrioma. In NMA, the reduction of postoperative AMH levels in the electrocoagulation (bipolar) group was higher than the suture group at 6 months with a statistical significance, and at 1, 3 and 12 months without a significant difference. The difference in the postoperative decrease of AMH level did not reach statistical significance between suture and sealant, coagulation and haemostatic sealant. The comprehensive ranking results revealed that suture treatment was, with the highest probability, beneficial to the protection of the ovarian reserve.

CONCLUSIONS

There was insufficient research to detect the optimal haemostasis method for ovarian reserve preservation in ovarian cystectomy. Nevertheless, haemostasis by electrocoagulation (bipolar) should be avoided when possible, and the suture might be considered as the best choice.

Impact of the hemostatic approach after laparoscopic endometrioma excision on ovarian reserve: Systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic excision of endometrioma and subsequent hemostasis have detrimental effects on ovarian reserve.

OBJECTIVES

To evaluate which hemostatic approach after stripping cystectomy shows less damage on ovarian reserve.

SEARCH STRATEGY

Embase, MEDLINE, Scopus, Scielo.br, LILACS, Cochrane Library at the CENTRAL Register of Controlled Trials, Clinicaltrials.gov, CINAHL, conference abstracts, and International Clinical Trials Registry Platform were searched from inception until April 2022.

SELECTION CRITERIA

Randomized controlled trials of women undergoing laparoscopic endometrioma excision that compared at least two hemostatic approaches.

DATA COLLECTION AND ANALYSIS

Relevant data were extracted and tabulated. Network meta-analysis based on random-effects model for mixed multiple treatment to rank hemostatic strategies using the surface under the cumulative ranking curve area (SUCRA) was performed. Quality assessment was performed using Cochrane criteria. The primary outcome was serum antimullerian hormone levels 3 months after surgery.

MAIN RESULTS

Ten studies, including 748 women, were selected. Suturing the ovary with barbed suture (SUCRA, 82.80%) seem the most effective strategy to avoid antimullerian hormone reduction. Similarly, for ultrasonographic antral follicular count, barbed (SUCRA, 30.70%) and simple suture (SUCRA, 30.70%) were ranked the best choices. Ovarian suturing with simple suture demonstrated lower follicle-stimulating hormone levels (SUCRA, 88.70%).

CONCLUSIONS

Suturing the ovary, with simple or barbed suture, seems the most effective approach to keep ovarian reserve higher.

Percutaneous catheter drainage combined with peritoneal dialysis for treating acute severe pancreatitis: a single-center prospective study

BACKGROUND

To investigate the efficacy of percutaneous catheter drainage (PCD) and peritoneal dialysis (PD) in the treatment of severe acute pancreatitis (SAP) and its underlying mechanism.

METHODS

Totally 64 SAP patients were included in our study and randomly assigned into PCD+PD group (the combination group, N.=32) and convention group (N.=32). SAP patients in the combination group were treated with percutaneous catheter drainage combined with peritoneal dialysis, while those in the convention group were treated with conventional method. The treatment efficacy of both methods were evaluated by comparing levels of plasma inflammatory cytokines (IL-6, IL-8, TNF-α, C-reactive protein, procalcitonin and leukocyte count), relative indexes of important organs (aspartate aminotransferase, alanine aminotransferase, creatinine and urea nitrogen) and other clinical data (amelioration time of abdominal pain and abdominal distension, Balthazar CT scores, acute physiology and chronic health enquiry II score, length of hospital stay, complications and prognosis).

RESULTS

The expression levels of inflammatory cytokines were significantly decreased in the combination group in a time-dependent manner in comparison with those of the convention group. In addition, the amelioration time of abdominal pain and abdominal distension, length of hospital stay, Balthazar CT scores and the acute physiology and chronic health care II scores in the combination group were also significantly decreased in comparison with those of the convention group.

CONCLUSIONS

The combination treatment of PCD and PD effectively relieves the clinical symptoms of SAP by clearing plasma inflammatory cytokines.

LPAR2 and LPAR4 are the Main Receptors Responsible for LPA Actions in Ovarian Endometriotic Cysts

Endometriosis has been considered as an estrogen (E2)-dependent and progesterone (P4)-resistant disease. On the other hand, lysophosphatidic acid (LPA) has been suggested as a significant modulator of ovarian pathology, acting via both LPA levels and LPA receptor (LPAR) upregulation. Therefore, the objective of the present study was to evaluate LPA concentration as well as LPARs, autotaxin (ATX), and phospholipase A2 (PLA2) expression in ovarian endometriotic cysts and normal endometrium with correlation of the expression of E2 and P4 receptors in endometriotic cysts. The analyses were carried out using the tissues derived from 37 patients with ovarian endometriosis and 20 endometrial samples collected from women without endometriosis were used as a control. We found that ovarian endometriotic cysts are a site of LPA synthesis due to the presence of enzymes involved in LPA synthesis in the tissue. Additionally, when we compared endometriotic cysts versus normal endometrium, we were able to show overexpression of 3 from 6 examined LPARs and both enzymes responsible for LPA synthesis in endometriotic cysts. Finally, we found the correlations between LPARs, ATX, and PLA2 and the expression of E2 and P4 receptors in endometriotic cysts. Owing to the high LPAR2 and LPAR4 transcript and protein expression in endometriotic ovarian cysts and positive correlations of both these receptors with the PR-B and ERβ, respectively, those receptors seem to be the most promising predictors of the endometriotic cysts as well as the main receptors responsible for LPA action in the ovarian endometriosis.

Effect of Surgical Removal of Endometriomas on Cyclic and Non-cyclic Pelvic Pain

BACKGROUND

Endometriosis is a complex disease with a spectrum of pain symptoms from mild dysmenorrhea to debilitating pelvic pain. There is no concrete evidence in the literature whether endometriotic cyst per se, causes pain spectrum related to the disease. The aim of the present study was to evaluate the effect of surgical removal of endome- triomas on pain symptoms.

MATERIALS AND METHODS

In this prospective, observational, before-after study, which was conducted between March 2012 and January 2013 in Training and Research Hospital,Adana, Turkey, a total of 23 patients including 16 sexually active and 7 vir- gin symptomatic women were questioned for non-cyclic pelvic pain (NCPP), intensity of the NCPP, presence of cyclic dysmenorrhea, and dyspareunia before and after the endometrioma operation. Participants who were sonographically diagnosed and later pathologically confirmed as having endometrioma without sign and symptoms of deep infiltrative endometriosis (DIE) were also questioned for pain symptoms before and after the laparoscopic removal of cyst wall. Patients with intraabdominal adhesions, history of pelvic inflammatory disease, and pathological diagnosis other than endometrioma were excluded. No ancillary procedures were applied for pain management, but if pain was present, pelvic peritoneal endometriotic lesions were ablated beside the removal of ovar- ian endometriotic cysts.

RESULTS

Out of 23 cases with endometrioma, 91 and 78% reported to have NCPP and dysmenorrhea, respectively, before the operation, while 60 and 48%, respec- tively, after the operation (McNemar's test, P=0.016 for both figures). Among the sexually active cases, 31% (5/16) had dyspareunia before the operation and only 1 case reported the pain relief after the operation (McNemar's test, P=1). Intensity of NCPP were reported to be none (8.7%), moderate (21.7%), severe (56.5%) and un- bearable (13%) before the operation and decreased to none (43.5%), mild (43.5%), moderate (4.3%) and severe (8.7%) after the operation (Wilcoxon signed-rank test, P<0.001).

CONCLUSION

In symptomatic cases with ovarian endometrioma, without sign and symptoms of DIE, laparoscopic removal of the cysts with/without ablation of the peritoneal endometriotic lesions yields relief of NCPP and cyclic dysmenorrhea, but not dyspareunia.

Gestrinone combined with ultrasound-guided aspiration and ethanol injection for treatment of chocolate cyst of ovary

AIM

The aim of this study was to determine clinical performance of gestrinone combined with ultrasound-guided aspiration and ethanol injection in treating chocolate cyst of ovary.

METHODS

Sixty-eight patients enrolled in this study were randomly divided into two groups: control group and combination treatment group. In the control group, 34 patients were treated with ultrasound-guided aspiration and ethanol injection. In the combination treatment group, 34 patients received gestrinone p.o. following ultrasound-guided aspiration and ethanol injection.

RESULTS

The recurrence rate of chocolate cyst was 10-fold lower in the combination treatment group (2.94%, 1/34) than in the control group (29.4%, 10/34) at 12 months. The effective rate for reduction of chocolate cyst was significantly higher in the combination treatment group (94.12%, 32/34) than in the control group (64.71%, 22/34) (P = 0.009).

CONCLUSION

Gestrinone combined with ultrasound-guided aspiration and ethanol injection therapy is an effective treatment for ovarian chocolate cyst with low recurrence rate.

Surgical strategy in endometriosis

Endometriosis is a common disease affecting young women. Its clinical manifestations include pain and infertility, and it can dramatically affect quality of life. Treatments should be tailored to address the wishes of women according to the specific characteristics of the disease. Although many questions remain unanswered, strong evidence supports the use of laparoscopic surgery to improve pain and infertility. The systematisation of strategy is essential to make surgery more reproducible, safer and less time-consuming. Nevertheless, even in the most expert hands, complications may occur. Further investigations are needed to compare the different approaches. Outcomes must, however, include pain, fertility, organ dysfunction, and quality of life.

Medical management of recurrent endometrioma with long-term norethindrone acetate

PURPOSE

Evaluate the efficacy of norethindrone acetate in the resolution of symptoms and regression of recurrent endometrioma.

PATIENTS AND METHODS

Retrospective chart review at SUNY Downstate Medical Center of patients with a history of surgical excision of endometrioma (with histological confirmation) and recurrent endometrioma (demonstrated by strict sonographic criterion of endometrioma) who were willing to undergo follow-up. Patients were prescribed norethindrone acetate to be taken daily with follow-up sonograms until cysts regressed. Statistical analysis included Student's t-test and a simple linear regression model to assess cyst regression over time during treatment.

RESULTS

Degree of pain was significantly lower on treatment when compared to baseline (P < 0.00001). Cyst size was significantly smaller in as little as 3 months (P < 0.0001). Average rate of regression with continuous treatment was 0.025 ± 0.015 cm/day. Total mean ± standard deviation regression time is 10.28 ± 8.25 months.

CONCLUSION

Norethindrone acetate was effective in eradicating symptoms and producing complete regression of recurrent endometriomas. It should be considered for patients who are likely to adhere to a prolonged treatment regimen and comply with recommendations for surveillance with serial sonograms.

Ultrasound-guided interventional therapy for recurrent ovarian chocolate cysts

The aim of this study was to determine the effectiveness of ultrasound-guided interventional therapy in the treatment of postoperative recurrent chocolate cysts. The 198 patients enrolled in this study were divided into three groups. In group 1, the saline washing group, the cavity of the cyst was washed thoroughly with warm saline. In group 2, the ethanol short-time retention group, after washing with saline, the cyst was injected with 95% ethanol with a volume of half of the fluid aspirated from the cyst. Ten minutes later, the rest of the ethanol was aspirated. In group 3, the ethanol retention group, the procedures were the same as with the ethanol short-time retention group, except that 95% of the ethanol was retained in the cyst. An ultrasound examination was performed in the third, sixth and 12th months after therapy. The chocolate cyst cure rate was significantly higher in the ethanol retention group (96%, 66/69) than in the ethanol short-time retention group (82%, 56/68) and no case was cured in the first group (saline washing). We conclude that ultrasound-guided injection and 95% ethanol retention are an effective therapy for the treatment of postoperative recurrent chocolate cysts.

Efficacy of laparoscopic stripping for ovarian cysts: histological and clinical findings

AIM

The aim of our study was to evaluate the efficacy of the laparoscopic stripping technique on benign ovarian masses with respect to healthy ovarian tissue.

MATERIAL AND METHODS

Seventy-six patients between 14 and 40 years of age were enrolled after receiving a diagnosis of mono-lateral ovarian cyst and underwent laparoscopic surgery for cyst excision with the stripping technique. Histological observations of these specimens were then performed and graded on a semiquantitative scale.

RESULTS

The 76 samples included 36 endometriotic cysts, 18 dermoid cysts, 12 serous cysts, and 10 mucinous cysts. Only 26 of the endometriomas showed histological evidence of healthy ovarian tissue that, however, differed morphologically from normal ovarian tissue.

CONCLUSION

The laparoscopic stripping technique used for the excision of different ovarian cysts is a practice that safeguards the organ.

Risk factors for recurrence and re-recurrence of ovarian endometriomas after laparoscopic excision

AIM

Since ovarian endometrioma is frequently diagnosed in women of reproductive age, laparoscopic excision of the endometrioma is performed for most cases. However, endometriomas frequently recurs even after repeated surgical procedures. The aim of our study is to identify risk factors for recurrence and re-recurrence of endometriomas after the first and second laparoscopic excision.

MATERIAL & METHODS

We retrospectively evaluated 173 patients who had a minimum of one year postoperative follow-up after the laparoscopic excision of endometriomas. Ten and eight factors were evaluated to assess their effect on the risk of recurrence and re-recurrence, respectively. Factors were analyzed using univariate and the Cox regression test.

RESULTS

The overall rate of recurrence and re-recurrence were 45.1% and 45.5%, respectively. A high revised American Society for Reproductive Medicine score (1997) was associated with an increased risk of recurrence. Only postoperative pregnancy was associated with a decreased risk of recurrence. Short periods of normal menstruation without pregnancy or gonadotrophin-releasing hormone analogues from first surgery to recurrence were associated with higher rate of re-recurrence.

CONCLUSIONS

A high revised American Society for Reproductive Medicine score was a risk factor, and postoperative pregnancy was protective against recurrence. The patient with short periods of normal menstruation without pregnancy or gonadotrophin-releasing hormone analogues from first surgery to recurrence had a high risk of re-recurrence.

Treatment of endometriosis with laparoscopic surgery today

Az endometriosis korszerű sebészi kezelésének célja a károsodott kismedencei anatómia helyreállításával az endometriosishoz társuló fájdalomtünetek csökkentése, illetve a teherbe esési esélyek javítása. Cikkünkben a különböző elhelyezkedésű kismedencei endometriosislaesiók eltávolításának műtéti lehetőségeit elemezzük. Az endometriosis sebészi kezelése döntően laparoszkópia útján valósul meg, míg a laparotomia alkalmazási köre egyre inkább beszűkült és csak speciális esetekre korlátozódik. A peritonealis endometriosis laesiói reszekció, elektrokoaguláció vagy lézervaporizáció segítségével kezelhetők, amelyek azonos mértékben csökkentik az endometriosishoz társuló fájdalomtüneteket, illetve javítják a teherbe esési esélyeket. Az endometrioma kezelésében hosszú éveken át kétféle műtéti megoldás terjedt el; a cisztatok eltávolítása az úgynevezett strippingtechnika segítségével, valamint a cisztatok megszüntetése az ablatiós műtéti technikával. Napjainkra egyértelműen bebizonyosodott, hogy a stripping előnyösebb az endometrioma ablatiójával szemben mind a fájdalomtünetek csökkenése, mind a reproduktív funkciók szempontjából. A mélyen infiltráló endometriosis kezelése jelenti a legnagyobb kihívást az endometriosis sebészetében. A mélyen infiltráló laesiók eltávolításában a lézertechnika alkalmazásának jut főszerep. A rectovaginalis septum endometriosisa esetén lézer segítségével a mélyen infiltráló laesio biztonsággal és maradéktalanul eltávolítható. Bélendometriosis esetén az érintett bélszakaszt szegmentális reszekcióval, discreszekcióval vagy az úgynevezett shavingtechnikával távolíthatjuk el. Leggyakrabban a szegmentális reszekciót alkalmazzuk, mivel egyedül ez esetben biztosítható a reszekciós szél biztos épsége. Az ureter endometriosisa esetén kisfokú érintettség mellett ureterolysis, míg obstruktív uropathia fennállásakor az ureter reszekciója javasolható. Az endometriosishoz társuló fájdalom hatékonyabb csökkentését célozza a praesacralis neurectomia és az uterusidegrost-ablatio. Ezen beavatkozások klinikai eredményessége azonban nem egyértelmű, az endometriosis kezelésében betöltött pontos szerepük tisztázása további vizsgálatokat igényel. Az endometriosis sebészetében a folyamatosan fejlődő műtéti technikák az endometriosislaesiók egyre teljesebb és hatékonyabb eltávolítását teszik lehetővé, amelynek köszönhetően egyre eredményesebben kezelhetők az endometriosishoz társuló klinikai tünetek és csökkenthető a betegség kiújulásának veszélye.

Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis

BACKGROUND

Endometriosis recurrence after conservative surgery is not infrequent. Variable regimens of hormonal therapy have been proposed as adjuvant post-operative measures for prophylaxis against recurrence. Among these, the combined oral contraceptive pills (OCP), represents a valuable option in terms of safety and tolerability for long-term use. The objective of this review is to evaluate the effect of post-operative use of OCP in preventing symptom recurrence, and/or anatomical relapse of endometriosis.

METHODS

A systematic search of Medline identified seven studies evaluating post-operative OCP treatment on prevention of endometriosis recurrence.

RESULTS

A reduction in anatomical relapse rate was observed when oral contraceptive therapy was administered for more than 1 year after conservative surgery. Post-operative use of OCP was associated with a reduction in frequency and intensity of dysmenorrhoea recurrence. No association was found between OCP therapy and dyspareunia prevention, although the effect of OCP on chronic pelvic pain was conflicting.

CONCLUSION

Long-term OCP therapy can be a reliable adjuvant post-operative measure to prevent or reduce frequency/severity of recurrent dysmenorrhoea and anatomical relapse of endometriosis. Since both continuous and cyclic OCP administration regimens seem to have comparable effects, the choice of regimen can be modulated according to patient preferences. The protective effect seems to be related to the duration of treatment.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

Excisional surgery versus ablative surgery for ovarian endometriomata

BACKGROUND

Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured over a laparotomy approach as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall.

OBJECTIVES

The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. The end-points assessed were the relief of pain, recurrence of the endometrioma, recurrence of symptoms and in women desiring to conceive the subsequent pregnancy rate, either spontaneous or as part of fertility treatment.

SEARCH STRATEGY

The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 3rd March 2007), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 3, 2007), MEDLINE (1966-August 2007), EMBASE (1980- March 2007) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world. The Cochrane Menstrual Disorders and Subfertility Group Trials Register is based on regular searches of MEDLINE, EMBASE, CINHAL and CENTRAL.

SELECTION CRITERIA

Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata.

DATA COLLECTION AND ANALYSIS

Reviewers assessed eligibility and trial quality.

MAIN RESULTS

No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size, for the primary symptom of pain were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of the symptoms of dysmenorrhea (OR 0.15 CI 0.06-0.38), dyspareunia (OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56), a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93) and with a reduced requirement for further surgery (OR 0.21 CI 0.05-0.79) than surgery to ablate the endometrioma. For those women subsequently attempting to conceive it was also associated with a subsequent increased spontaneous pregnancy rate in women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29). A further randomised study was identified that demonstrated an increased ovarian follicular response to gonadotrophin stimulation for women who had undergone excsional surgery when compared to ablative surgery (WMD 0.6 CI 0.04-1.16). There is insufficient evidence to favour excisional surgery over ablative surgery with respect to the chance of pregnancy after controlled ovarian stimulation and intra-uterine insemination (OR 1.40 CI 0.47-4.15) .

AUTHORS' CONCLUSIONS

There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy . Consequently this approach should be the favoured surgical approach. However in women who may subsequently may undergo fertility treatment insufficient evidence exists to determine the favoured surgical approach.

Patterns of and risk factors for recurrence in women with ovarian endometriomas

OBJECTIVE

To identify risk factors for and the patterns of recurrence of endometrioma and of dysmenorrhea in women with ovarian endometrioma.

METHODS

We evaluated 710 consecutive patients operated on for ovarian endometriomas who were followed up for an average of 22.4 months. Twenty factors were examined to assess their effect on risk of recurrence of endometrioma and of dysmenorrhea using survival analysis. Hazard rate also was estimated to examine recurrence patterns.

RESULTS

For recurrence of endometrioma, the revised American Fertility Society (rAFS) score, younger age at surgery, and previous medical treatment of endometriosis were identified to be risk factors. For recurrence of dysmenorrhea, rAFS score was the only risk factor. For both recurrences, there was a constant hazard rate in the first 28-30 months after surgery, indicating that the recurrence in that period is completely random. After that period, the hazard rate increased dramatically.

CONCLUSION

The total rAFS score, but not rAFS stage, is a risk factor for recurrence of both endometrioma and dysmenorrhea, indicating that the rAFS stage has little prognostic value. The existence of a completely random recurrence period may be a universal phenomenon, with its duration and the magnitude of recurrence risk determined by patient characteristics and quality of care. The second phase of much higher recurrence risk may reflect successful reseeding, reimplantation, and regrowth of ectopic endometrium. Therefore, the identification of risk factors as well as patterns of recurrence should shed better light on possible causes for recurrence, which is now poorly understood.

Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery

STUDY OBJECTIVE

This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management.

DESIGN

Retrospective analysis of 62 reproductive-age women who showed recurrence of endometriomas on TVS after laparoscopic removal of an ovarian endometrioma by the stripping technique (Canadian Task Force classification II-1).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

Sixty-two patients with recurrent endometriomas after first-line treatment with laparoscopy.

INTERVENTIONS

Ultrasonographic follow-up and/or second surgery.

MEASUREMENTS AND MAIN RESULTS

Recurrence of an ovarian endometrioma was defined as the presence of ovarian cysts with the typical sonographic criteria of endometriomas and a diameter of more than 10 mm. The clinical and sonographic postoperative follow-up period lasted from 6 to 97 months (median 24.6) after the first procedure. Of 62 patients with recurrent endometriomas, 50 had recurrence on the treated ovary, 7 on the contralateral untreated ovary, and 5 on both the treated and untreated ovaries. Recurrence of endometriomas was associated with symptoms (pain or infertility) in 47 patients (76%), while the remaining 15 (24%) were asymptomatic. Of the 47 symptomatic patients with recurrence detected by TVS, a second procedure was performed in 15. Second surgery in these patients was indicated by the larger size of the recurrent cysts, a poor response to medical treatment, the presence on TVS of pelvic adhesions and nodules of deep endometriosis, and overall progression of the disease. Symptomatic patients who did not undergo a second procedure (32) had smaller recurrent endometriomas. However of the 31 symptomatic patients with large recurrent endometriomas (>3 cm), only 45% had repeat surgery.

CONCLUSION

Recurrent endometriomas, as detected by TVS, can remain asymptomatic and do not necessarily progress in size with or without medical treatment. The decision to reoperate depends less on the endometrioma's size than on symptoms, in particular severe pain, and failure of medical treatment. However such patients are also more likely to have signs of deep nodules and adnexal/bowel adhesions and larger endometriomas on TVS scan, thus predisposing them to require a second procedure.

Recurrence of ovarian endometrioma after laparoscopic excision

BACKGROUND

To analyse risk factors that influence the recurrence of endometrioma after laparoscopic excision.

METHODS

A total of 224 patients who had a minimum of 2 years of post-operative follow-up after laparoscopic ovarian endometrioma excision were studied retrospectively. Recurrence was defined as the presence of endometrioma more than 2 cm in size, detected by ultrasonography within 2 years of surgery. Fourteen variables (age, presence of infertility, pain, uterine myoma, adenomyosis, previous medical treatment of endometriosis, previous surgery for ovarian endometriosis, single or multiple cysts, the size of the largest cyst at laparoscopy, unilateral or bilateral involvement, co-existence of deep endometriosis, revised American Society for Reproductive Medicine (ASRM) score, post-operative medical treatment and post-operative pregnancy) were evaluated to assess their independent effects on the recurrence using logistic regression analysis.

RESULTS

The overall rate of recurrence was 30.4% (68/224). Significant factors that were independently associated with higher recurrence were previous medical treatment of endometriosis [odds ratio (OR) = 2.324, 95% confidence interval (95% CI) = 1.232-4.383, P = 0.0092) and larger diameter of the largest cyst (OR = 1.182, 95% CI = 1.004-1.391, P = 0.0442). Post-operative pregnancy was associated with lower recurrence (OR = 0.292, 95% CI = 0.028-0.317, P = 0.0181).

CONCLUSIONS

Previous medical treatment of endometriosis or large cyst size was a significant factor that was associated with higher recurrence of the disease. Post-operative pregnancy is a favourable prognostic factor.

Is there any correlation between stages of endometriosis and severity of chronic pelvic pain? Possibilities of treatment

We report herein findings on 181 patients, suffering from pelvic endometriosis confirmed by histology, whose main symptom was chronic pelvic pain (CPP). They attended the outpatient clinic at the 1st Department of Obstetrics and Gynaecology, Semmelweis University in Budapest, between 1 January 1995 and 1 January 2000. The extent of pelvic endometriosis was determined on the basis of the 1985 revised scoring system of the American Fertility Society (R-AFS). The short form of the McGill pain questionnaire was used for the evaluation of CPP. After the first operative intervention, therapy with a gonadotropin-releasing hormone (GnRH) analog was given for 6 months. Second-look laparoscopy was performed 8-10 weeks after the end of GnRH-analog treatment, which was followed by a non-conventionally administered, monophasic oral contraceptive (OC) treatment. In the long term, 118 patients received the non-conventionally administered, monophasic OC treatment, which contained a third-generation progestogen, to be taken continuously for at least 6 months. The other 63 patients who did not receive OC treatment for one reason or another were evaluated as a control group. We analyzed data on CPP before the first surgical intervention, then following therapy with the GnRH analog at the second-look operation, and then after 6, 12, 18 and 24 months. We also reviewed potential causes of CPP, especially focused on endometriosis. No correlation was found between the stage of endometriosis according to R-AFS score and the severity of CPP. At the 24-month follow-up after second-look laparoscopy, the non-conventionally administered monophasic OC treatment was found not only to significantly reduce pain scores, but also the required radical operative solution (hysterectomy plus bilateral adnexectomy) for CPP by OC users.

Excisional surgery versus ablative surgery for ovarian endometriomata

BACKGROUND

Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured for as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall.

OBJECTIVES

The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, with regard to relief of pain, recurrence of the endometrioma, recurrence of symptoms and the subsequent spontaneous pregnancy rate.

SEARCH STRATEGY

The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 15 Nov 2004), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966-Nov 2004), EMBASE (1980- Nov 2004) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world.

SELECTION CRITERIA

Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata.

DATA COLLECTION AND ANALYSIS

Reviewers assessed eligibility and trial quality.

MAIN RESULTS

No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93), reduced requirement for further surgery (OR 0.21 CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15 CI 0.06-0.38), dyspareunia OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56). It was also associated with a subsequent increased rate of spontaneous pregnancy women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29).

AUTHORS' CONCLUSIONS

There is some evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However we found no data as to the effect of either approach in women who subsequently undergo assisted reproductive techniques.

Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part II: pathological results

BACKGROUND

The stripping technique for endometriomas excision has been reported to be associated with follicular loss. The objective of this trial was to evaluate the presence and nature of ovarian tissue adjacent to the endometrioma cyst wall obtained by stripping with different techniques.

METHODS

Forty-eight patients with ovarian endometrioma were enrolled in two consecutive independent randomized trials. Two different techniques were analysed at the initial adhesion site (circular excision and subsequent stripping versus immediate stripping). Two different techniques were analysed at the ovarian hilus (stripping versus coagulation and cutting). Histology analysis was performed in three portions of the cyst wall (initial adhesion site, intermediate part of the specimen, ovarian hilus).

RESULTS

Recognizable ovarian tissue was inadvertently excised together with the endometrioma cyst wall in most cases. At initial adhesion sites more ovarian tissue was removed with the circular excision technique (< 0.001). No significant difference in quality of ovarian tissue (number and type of follicles) was found between specimens obtained with different surgical techniques at the initial or at the final part of the procedure. At the initial adhesion site and at the intermediate part of the cyst wall, the ovarian tissue removed along with the endometrioma wall was mainly constituted by tissue with no follicles or only primordial follicles (60% and 48% of the specimens from the initial part with both techniques, and from the intermediate part, respectively, had no follicles or only primordial follicles). Close to the ovarian hilus the ovarian tissue removed along with the endometrioma wall mostly consisted of tissue which contained primary and secondary follicles (69% of the cases, combining the two groups).

CONCLUSIONS

Ovarian tissue is inadvertently excised together with the endometrioma wall in most cases. The excised tissue is at normal functional development stages only near the ovarian hilus. The different techniques used do not influence significantly the quality of the resected tissue.

Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part I: Clinical results

BACKGROUND

Laparoscopic surgery has become the gold-standard treatment for ovarian endometriomas. The objective of this trial was to evaluate different procedures for the laparoscopic excision of ovarian endometriomas with the stripping technique.

METHODS

Forty-eight patients with ovarian endometrioma were enrolled in two consecutive independent randomized trials. Two different techniques were analysed at the initial adhesion site (circular excision and subsequent stripping versus immediate stripping). Two different techniques were analysed at the ovarian hilus (stripping versus coagulation and cutting). Operative time and technical difficulties were prospectively evaluated. Histological analysis was performed in three portions of the cyst wall and the results of the histologic study are reported separately.

RESULTS

At the initial part of the stripping procedure, the technique of circular excision and subsequent stripping appeared to be more easily performed than the technique of direct stripping (P < 0.01), although operative times were comparable between the two techniques. At the hilus, the two techniques utilized appeared to be comparable both for easiness of procedure and operating times.

CONCLUSIONS

In this prospective, randomized study, different techniques used during the stripping procedure appeared to be comparable in terms of operative times and complications. One technique used at the beginning of the procedure (circular excision followed by stripping) was easier to perform.

A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas

OBJECTIVE

To determine the difference between two laparoscopic methods for the management of endometriomas with regard to recurrence of signs and symptoms and pregnancy rate.

DESIGN

Prospective, randomized clinical trial.

SETTING

Infertility and gynecologic endoscopy units of two medical university hospitals.

PATIENT(S)

One hundred patients with endometriomas who had either infertility or pelvic pain.

INTERVENTION(S)

Patients were randomly divided into two groups; one group underwent cystectomy (group 1), and fenestration and coagulation were performed for the other (group 2).

MAIN OUTCOME MEASURE(S)

A comparison of recurrence of signs and symptoms of endometriomas and pregnancy rates in two groups.

RESULT(S)

Fifty-two patients were studied in group 1 and 48 in group 2. The recurrence of symptoms, such as pelvic pain and dysmenorrhea, was 15.8% in group 1 and 56.7% in group 2 after 2 years. The rate of reoperation was 5.8% in group 1 and 22.9% in group 2 and these differences were statistically significant. The cumulative pregnancy rate was significantly higher in group 1 (59.4%) than in group 2 (23.3%) at 1-year follow-up.

CONCLUSION(S)

Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter.

Ablative or excisional laparoscopic surgery for endometriotic cysts: resolving the issue

A logistic regression analysis was carried out to compare laparoscopic excision with ablation for endometriotic cysts. Four comparative studies were identified. Cyst recurrence (%, +/- SE) was twice as likely after the ablation treatment (26.6% +/- 0.032) than after the excision treatment (13.2% +/- 0.019), (p <.001, relative risk 1.9). Two comparative studies were identified where postprocedure pregnancy rates were an outcome measure. Postoperative pregnancy rates were not significantly different for the ablation treatment (41.6% +/- 0.138) than for the excision treatment (56.9% +/- 0.23). There was only one comparative study to investigate symptom relief, therefore logistic regression analysis to compare studies was not possible. Three studies compared excisional surgery and perioperative medication with excisional surgery only. Cyst recurrence rates were not significantly different for the group that received medication (10.3% +/- 0.033) than for the group that did not (4.0% +/- 0.02).

Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue

OBJECTIVE

The aim of this study was to determine whether and to what extent laparoscopic removal of ovarian endometriotic cysts is a tissue-sparing procedure.

STUDY DESIGN

At the University Hospital, 77 women of reproductive age with endometriomas and 55 with dermoid cysts underwent laparoscopic removal of the ovarian disease by stripping. Within 1 month before and within 36 months after surgery all patients underwent transvaginal sonographic evaluation of ovarian volume of the endometriomas or dermoid cysts and measurement of the residual ovarian tissue.

RESULTS

The residual ovarian volume after surgery was significantly less for the endometrioma group than for the dermoid group. Comparison of the volume of the treated ovary with that of the untreated contralateral ovary showed a significant difference (4.3+/-2.3 cm(3) vs 9.7+/-3.9 cm(3)) only in the endometrioma group.

CONCLUSION

Ovarian stripping of endometriomas, but not of ovarian dermoids, is associated with a significant decrease in residual ovarian volume which may result in diminished ovarian reserve and function.

Chemically assisted dissection of tissues in laparoscopic excision of endometriotic cysts

STUDY OBJECTIVE

To evaluate the capacity of chemical dissection of tissues using a mucolytic substance, Mesna, in improving laparoscopic excision of endometriotic cysts.

DESIGN

Randomized, double-blind, controlled trial (Canadian Task Force classification I).

SETTING

University-affiliated training hospital.

PATIENTS

Forty-four women with symptomatic ovarian endometriotic cysts. Intervention. Laparoscopic excision of endometriotic cysts in 22 women with the aid of Mesna solution and in 22 with the aid of saline solution.

MEASUREMENTS AND MAIN RESULTS

In comparison with saline solution, Mesna as a chemical dissector resulted in significant reductions in operating time, in difficulty encountered by the surgeon to enucleate the cysts, and in less bleeding. No differences were found in length of hospital stay, costs of surgeries, analgesic requirement, and fever. Postoperatively, patients treated with Mesna achieved more pregnancies than those treated with saline.

CONCLUSION

Chemical dissection of tissues with Mesna proved to be a safe and suitable support in laparoscopic surgery for ovarian endometriotic cysts.

Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III-IV endometriosis and endometriotic cysts

OBJECTIVE

To document the changes in pain scores 3-12 months following ablative laparoscopic surgery. Secondary outcome measures included patient satisfaction scores.

DESIGN

A prospective, cohort study.

SETTING

A tertiary referral center for the treatment of endometriosis.

PATIENT(S)

Seventy-three consecutive women with stage III-IV endometriosis and an endometrioma >2 cm.

INTERVENTION(S)

A laparoscopy was performed. The extraovarian endometriosis was ablated with a CO(2) laser, and the endometrioma capsule was fenestrated then ablated with the potassium-titanic-phosphate (KTP) laser or the Bicap bipolar diathermy.

MAIN OUTCOME MEASURE(S)

Pre- and postoperative visual analogue scores for pelvic pain were completed. Patient satisfaction was scored from 1 to 10, with a score of 10 being "most satisfied."

RESULT(S)

A total of 73 women with stage III-IV endometriosis and 96 cysts (23 cysts were bilateral). The mean revised American Fertility Society (AFS) score was 65.5 (range 22-128). At 12 months, the mean temporal decrease in the pain score for dyspareunia was 2.14 +/- 0.41; for dysmenorrhea, 1.52 +/- 0.38; and for chronic nonmenstrual pain, 2.37 +/- 0.43. Sixty-four (87.7%) patients were satisfied or very satisfied with the treatment. No surgical complications occurred.

CONCLUSION(S)

Laparoscopic ablative surgery for endometriomas in the presence of stage III-IV endometriosis is an effective treatment for relieving pelvic pain.

Coagulation or excision of ovarian endometriomas?

A systematic review was undertaken to determine whether coagulation or laser vaporization of endometriomas is associated with an increase in the risk of cyst recurrence compared with excision of the pseudocapsule. In the four comparative trials identified, endometrioma recurrence was reported in 39 of 212 (18.4%) women treated with coagulation or laser vaporization compared with 19 of 295 (6.4%) in those who underwent cystectomy. The odds ratios of endometrioma recurrence ranged from 1.41 to 9.38 with 95% CIs including unity in two studies. The common odds ratio was 3.09 (95% CI 1.78-5.36). Coagulation or laser vaporization of endometriomas without excision of the pseudocapsule seems to be associated with a significant increase in risk of cyst recurrence.

Recurrence of chocolate cysts after laparoscopic ablation

STUDY OBJECTIVE

To estimate the recurrence rate of chocolate cysts 3 to 12 months after ablative laparoscopic surgery. The secondary outcome measure was the need for a repeat surgical procedure.

DESIGN

Prospective cohort study (Canadian Task Force classification II-2).

SETTING

Tertiary referral center for laparoscopic treatment of endometriosis.

PATIENTS

Seventy-three consecutive women with chocolate cysts larger than 2 cm.

INTERVENTION

Laparoscopy at which cyst capsules were vaporized or coagulated with the potassium-titanyl-phosphate (KTP) laser or Bicap bipolar diathermy.

MEASUREMENTS AND MAIN RESULTS

There were 96 cysts (23 bilateral) in 73 women (1 patient underwent a two-stage procedure). Their mean diameter was 4.79 cm (range 2-25 cm). The median r-AFS score was 56 (range 22-128), and 55 patients (75.3%) had stage 4 disease. The KTP laser was used in 50 women (68.5%) and bipolar diathermy in 23 (31.5%). At 12 months, 5 patients (6.9%) were lost to follow-up, and 12 had a recurrent cyst. Therefore, the cyst recurrence rate/patient was 16.4% (12/73) and the rate/cyst was 12.5% (12/96). Women who had recurrences were significantly more likely to have bilateral cysts, 7/12 (58.3%), than those with single cysts, 16/61 (26.2%, p =0.032). Bicap bipolar diathermy was associated with a recurrence rate of 20.8% (5/24). The rate in women who had KTP laser ablation was 14.3% (7/49, NS). Eighteen patients had repeat operations (including on recurrent cysts). Therefore the reoperation rate was 24.6% (18/73). No major surgical complications occurred. One woman had a postoperative wound infection after a second procedure to remove an ovary with a recurrent cyst.

CONCLUSION

Laparoscopic cyst fenestration followed by capsule ablation is safe and effective treatment for preventing recurrence of chocolate cysts.

Fertility after laparoscopic surgery for endometriomas

There are a number of published studies documenting pregnancy rates after endoscopic surgery in patients with endometriomas. These reports present similar pregnancy rates regardless of the surgical technique used to treat the cyst. This finding indicates that it does not matter whether the endometrioma is excised or ablated. However, debate about the nature of the cleavage plane of the cyst has led some surgeons to suggest that excision may damage the follicular reserve of the ovary. Furthermore, pregnancy rates after surgery cannot be compared in the same way as pregnancy rates after in vitro fertilization and embryo transfer because of lack of standardization. A review of the published studies relating to the laparoscopic management of endometriomas was performed to examine this issue further. Each paper was analysed using pre-set criteria to identify the methodology used and how the results were presented. Wide variation was found in the criteria used to select patients and in the way the results were reported. In view of these findings, there is an urgent need for surgical studies with consistent definitions of infertility and end-points, or a national system of audit.

Pregnancy rates following ablative laparoscopic surgery for endometriomas

BACKGROUND

In this prospective, cohort study we present the cumulative pregnancy rate following ablative laparoscopic surgery in patients with endometriomas.

METHODS

The cyst was mobilized, fenestrated, and the capsule treated with the potassium-titanyl-phosphate (KTP) laser or bipolar diathermy. Pre- and post-operative transvaginal ultrasound scans were performed, and a detailed fertility history recorded.

RESULTS

There were 39 women (38 intention to treat as a single procedure) who had been trying to conceive for >12 months. The mean age of the patients was 33.8 years (range 20-43), and there were 42 cysts (three bilateral) with a mean diameter of 4.8 cm (range 2-25). The mean revised American Fertility Society score was 64.9 (range 22-124), and 29 (74.4%) patients had stage IV disease. Seven patients (18%) had previously had a live birth, and 17 (43.6%) had undergone assisted conception in the past. The cumulative pregnancy rate was 15/38 (39.5%). The pregnancy rate in patients with stage IV disease was 11/28 (39.3%). There were no major complications.

CONCLUSIONS

Our results indicate that laparoscopic cyst fenestration and capsule ablation is a safe and effective treatment for improving fertility.

Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure?

OBJECTIVE

To determine whether the stripping technique by laparoscopy is a tissue-sparing procedure.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Forty-two women, 21 to 35 years of age, who had a unilateral ovarian cyst (26 endometriomas, 7 serous, 6 dermoid, and 3 mucinous cysts).

INTERVENTION(S)

Laparoscopic excision of ovarian cysts by using the stripping technique.

MAIN OUTCOME MEASURE(S)

Histologic analysis of the excised specimens was done to evaluate the presence and nature of ovarian tissue adjacent to the cyst wall.

RESULT(S)

Recognizable ovarian tissue adjacent to the cyst wall was present in 15 of 42 excised specimens (36%). A significant difference was present for endometriomas versus non-endometriosis cysts (ovarian tissue was present in 14 of 26 specimens [54%] vs. 1 of 16 specimens [6%]; P<.005). No specimen showed the normal follicular pattern observed in healthy ovaries.

CONCLUSION(S)

The stripping technique appears to be a tissue-sparing procedure. In 36% of the cysts, ovarian tissue is excised together with the cyst wall, but this tissue does not show the morphologic characteristics observed in normal ovarian tissue.