Endometriosis NEWS.Direct!

Volume 01, Issue 04

December 2010 - January 2011

ENDOMETRIOSIS NEWS.Direct!

Surgical Management of Endometriosis Brief Review of Current Evidence and Guidelines INTERVIEW

Dr. Tal Jacobson

Clinical Perspectives Minimally Invasive Surgery for Endometriosis

FEATURED MINI REVIEW New Evidence Validates Non-contraceptive Use of LNG-IUS for Endometriosis Management

MINI REVIEWS and NEWS Introital 3D Transvaginal Sonography Effective in Preoperative Diagnosis of Rectovaginal Septal Endometriosis Endometriosis Implicated in the Aetiology of Sacral Radiculopathies and Sciatica

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Identical Outcomes after Robot-assisted and Standard Laparoscopic Treatment of Endometriosis Better Survival Rates for Endometriosis-associated Ovarian Cancer Compared to Ovarian Cancer

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ENDOMETRIOSIS NEWS.Direct!

CONTENTS

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Editorial Advisory Board

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Dr. Nicolas Bourdel

Chief Consultant, Department of ObGyn and Reproductive Medicine, Credence Hospital, Trivandrum, India

Surgical Management of Endometriosis: Brief Review of Current Evidence and Guidelines

Dr. Shylaja B. Rajiv, Dr. B. M. John

CHU Clermont Ferrand, Department of ObGyn, La Polyclinique, Clermond Ferrand, France

Dr. Santhamma Mathew

Featured Article

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Interview Clinical Perspectives - Minimally Invasive Surgery for Endometriosis Dr. Tal Jacobson

Dr. Paul P. G. Chief Consultant and Laparoscopic Surgeon, Paul’s Hospital, Kochi, India

Dr. Pratap Kumar

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Head, Division of Reproductive Medicine Kasturba Medical College and Kasturba Hospital Manipal, India

16 All rights reserved Š 2011

INFORMATION

For complete Terms of use: www.endometriosis.in/?page_id=62 Editorial Process: www.endometriosis.in/?page_id=60 Cover Image Courtesy: Dr Paul PG, India

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New Evidence Validates Non-contraceptive Use of LNG-IUS for Endometriosis Management

Mini Reviews Introital 3D Transvaginal Sonography Effective in Preoperative Diagnosis of Rectovaginal Septal Endometriosis

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Better Survival Rates for Endometriosisassociated Ovarian Cancer Compared to Ovarian Cancer

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Laparoscopic Ureterocystoneostomy Offers Better Outcome in Ureteral Endometriosis

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Endometriosis Implicated in the Aetiology of Sacral Radiculopathies and Sciatica

For contributions, guidelines, and comments: editor@endometriosis.in For advertisements and reprints: sales@endometriosis.in

Featured Mini Review

News

Editorial Team

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Managing Editor Dr. B. M. John

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Study Highlights the Effectiveness of Laparoscopy in Bladder Endometriosis Management

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Identical Outcomes after Robot-assisted and Standard Laparoscopic Treatment of Endometriosis

Assistant Content Editor Dr. Shylaja B. Rajiv Assistant Copy Editor Amoolya Moses Research Analysts Dhanya Mohan Dr. Raghavendra Rao Design Veeresh Mathapati

Designed and Published On behalf of Endometriosis NEWS.Direct! by iLogy Healthcare Solutions www.ilogy.com Disclaimer Views and opinions expressed in this publication are not necessarily those of iLogy. iLogy reserves the right to use the information published herein in any manner whatsoever. While every effort has been made to ensure accuracy of the information published in this edition, neither iLogy and its employees nor its information vendors and advertisers accept responsibility for any errors or omissions. Further, iLogy, its information vendors and advertisers do not take any responsibility for loss or damage incurred or suffered by any reader of this magazine as a result of accepting any invitation/offer published in this edition. Please read the complete “Terms of Use� for more information.

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Central Sensitisation Probable Mechanism for Endometriosis-associated Hyperalgesia

Endometriosis NEWS.Direct!

December 2010-January 2011

FEATURED ARTICLE Surgical Management of Endometriosis:

Brief Review of Current Evidence and Guidelines Dr. Shylaja B. Rajiv, Dr. B. M. John

Introduction

• Recurrence of endometriosis • Moderate to severe endometriosis, especially in patients with endometriomas • Need for reconstruction of organs, as in patients requiring infertility treatment • Endometriosis emergencies like ruptured endometriomas, obstructive uropathy, bowel obstruction, and torsion of endometriomas

Endometriosis is a difficult disease to diagnose, with some settings reporting a diagnostic delay of up to 12 years.1 Although several methods have been used to detect endometriosis, including patient history, gynaecological examination, hysteroscopy, MRI, ultrasound, measurement of cancer antigen (CA) 125 levels, etc, the diagnosis is till a major challenge owing to its heterogenous nature and the symptomatic diversity (absent or mild-to-severe).1, 2 Apart from this, none of these tests can definitely confirm or exclude the presence of this intriguing gynaecological disorder.1

The extent to which surgery is performed is based on the disease severity and the preoperative symptoms.7 The surgical approaches may be either conservative, in which the surgeon excises all the lesions and associated adhesions and retains the healthy tissues, or radical, including procedures such as hysterectomy with bilateral salpingo-oophorectomy and resection. Some of the surgical treatment procedures that are commonly performed include adhesiolysis, endometriotic cyst excision, cyst wall ablation, cyst drainage, laser or diathermy ablation of endometriotic implants, uterosacral nerve ablation and presacral neurectomy (PSN).8, 9

The European Society of Human Reproduction and Embryology (ESHRE) has reiterated that laparoscopy, considered to be the ‘gold standard’, helps in visually inspecting the pelvis and in the definitive diagnosis of almost all types of endometriosis.3 Laparoscopy can also help in treating endometriosis at the time of diagnosis itself, besides offering its innate benefits such as small incisions, less trauma, and quick recovery time.1

Surgical Treatment Since the aetiology of endometriosis is unknown, there is no treatment that can cure the disorder, and also, there is lack of sufficient evidence to select a particular type of treatment over the other.4 Although medical therapy may aid in relieving pain and has low initial cost, it does not improve fertility, and is associated with high recurrence rates and adverse effects. Surgical therapy is proven to provide pain relief in the long-term, and additionally, several trials have concluded that surgery increases pregnancy rates and is the preferred treatment of choice for infertile patients suffering from endometriosis.5

Over the past four decades, technological advancements have resulted in the development of various surgical instruments and methods, which have different degrees of effectiveness. This includes tools such as lasers, microelectrodes, microsurgery and harmonic energy sources, which help in resecting, cauterising, and vaporising endometriosis. In 2010, Nácul and Spritzer reiterated the usefulness of laparoscopy in diagnosing endometriosis and indicated that surgery, ovarian suppression or both are the most common therapeutic strategies utilised for the disorder.10

In routine clinical practice, surgery is commonly recommended in the following scenarios:6 • Symptoms are acute, severe, or incapacitating • Failure of medical treatment • Intolerance/non-compliance to medical therapy • Anatomic disruption of pelvic cavity or urinary tract obstruction

Surgical Techniques

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Surgical treatment of endometriosis and endometriomas may be considered in the following cases: • Patients with pain • Infertility • Endometriomas with diameter >4 cm in asymptomatic patients

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Commonly used techniques during laparoscopic surgery have been described in brief below:

the enhanced risk of injury to underlying and adjacent structures, coagulation may not be effective in the removal of all types and stages of endometriosis, and therefore is not considered to be a good therapeutic option, according to the members of American Academy of Gynecologic Laparoscopists (AAGL).

Laparoscopic excision: Excision of endometriotic deposits or lesions is commonly performed either mechanically or by using energy sources. The former involves the use of mechanical shearing forces by instruments such as scissors, while the latter produces intense heat by laser, electrosurgery or harmonic scalpel, resulting in the vaporisation of lesions. Laparoscopic electrosurgical excision of endometriotic implants is associated with significant decrease in pain, improvement of quality of life, and reduced complication rates.11

Studies have demonstrated that coagulation can effectively treat small lesions ≤2 mm, and excision or vaporisation can be performed for those lesions between 3 mm and 5 mm. Although not many prospective randomised studies have compared coagulation with excision, the latter technique was found to be better in the management of deep lesions, especially disease in the proximity of vital organs.16 There is enhanced risk of thermal injury to adjacent tissues with increased exposure to electrosurgical coagulation as it may make the planes ambiguous. Some of the other limitations of coagulation are listed below: • Difficult to differentiate between normal and abnormal tissues due to the destruction of the tissue appearance • Does not help in clearly identifying the exact depth of the lesion • Increased risk of under-treatment, i.e., may not help in complete removal of the lesion, especially in deep endometriosis • Enhanced risk of over-treatment, which may damage the underlying vital structures

The laparoscopic management of endometriomas is more complex and requires greater surgical skill and judgement. A 2008 Cochrane review has recommended that excisional surgery for endometriomas is more effective than ablation and drainage in reducing the recurrence of pain and the disease, and also in improving the spontaneous pregnancy rates in subfertile women.

However, there is insufficient evidence to identify the optimal surgical strategy in patients who may undergo fertility treatment subsequently, with the debate whether surgery would lower the ovarian function.12 A 2009 review by Busacca and Vignali noted the lack of definitive data to confirm whether the damage to the ovarian reserve is due to the surgery, the cyst or a combination of both. Electrosurgical coagulation during haemostasis was also observed to be linked to the ovarian stroma and vascularisation injury.13

In a 2003 review, Davis and McMillan suggested the following methods to effectively manage the disease: • Minimal and mild endometriosis: Coagulation or laser vaporization • Moderate and severe endometriosis: Combination of laparoscopic excision and coagulation/laser vaporisation of superficial implants

Recently, researchers have suggested that endometrioma excision partly followed by the vaporisation of the remaining part of the lesion wall (10-20%) may be useful in the management of endometriomas as it did not adversely affect the ovaries.14

The National Institute for Health and Clinical Excellence interventional procedure guidelines suggest the use of laparoscopic helium plasma coagulation for vaporising endometriosis lesions. Also, the Specialist Advisors observed that the procedure was associated with lower lateral burning compared to diathermy and may permit the treatment of women on a day-case basis. Although the technique is considered to be safe, data on its efficacy is not sufficient to be adopted without special preparation for audit, research, or consent.17

According to the recommendations of a 2010 practice bulletin from the American College of Obstetricians and Gynecologists (ACOG), laparoscopic cyst excision should be the treatment of choice in patients who want to retain fertility as it offers favourable outcomes, i.e., low recurrence rates compared to drainage and coagulation.15 Coagulation: Various tools such as lasers, harmonic scalpel, endocoagulator, and monopolar and bipolar electrosurgery are commonly used to coagulate the lesions. These techniques involve the destruction of disease lesions using an energy source. Apart from

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Vaporisation: The vaporisation process, which involves the conversion of solids or liquids into gaseous form

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within the treated cell with no burning, can be linear or ablative. Linear vaporisation, which removes the lesions in a line, does not alter the cell appearance since it does not conduct heat, making it the preferred approach for the management of endometriosis. With similar advantages as linear, ablative vaporisation aids in removal of the tissue layer by layer, with no thermal injury to the underlying tissues.

ablation. Hence ablation is suggested as a secondary tool to excision. Electrosurgery, laser, bipolar diathermy and ultrasonic energy can be used for ablation, but several studies highlight the advantages of laser over the other tools, including accurate assessment of implant depth and restriction of ‘star-burst’ effect.21

Surgical Tools Some of the different surgical tools used in the treatment of endometriosis are mentioned below.

There are equivocal results on the effectiveness of ablation in the management of endometriosis. Recently, UK-based researchers assessed the usefulness of laparoscopic ablative surgery in a prospective cohort study, and reported that it could serve as a good option for the treatment of even stage III-IV endometriosis and endometriomas >2 cm.18 Similarly, a 2002 study published in the journal Human Reproduction, reported that laparoscopic cyst fenestration and ablation of capsule could improve fertility, as well as decrease cyst recurrence.19 Cibula and coworkers in 2003 noted that pain reduction in patients with peritoneal endometriosis following ablation lasted for 18 months, but the number of recurrences gradually increased during longer term follow-up.20

Laser Technique: Various types of lasers, such as carbon dioxide laser, the argon laser, potassium titabyl phosphate (KTP) and the neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, have been used in laparoscopy for the management of endometriosis. Data from trials have suggested the following applications for various lasers:24 Type of laser

Uses

CO2 laser

Mild-to-moderate endometriosis

Argon laser

Vaporisation of large cysts

Potassium titabyl phosphate Large deeply embedded cysts laser

A 2007 review by Kenny and English observed that superficial endometriosis is usually treated with laparoscopic ablation by many gynaecologists.21 Similarly, according to a 2004 survey of the gynaecologists from the Royal College of Obstetricians and Gynaecologists (RCOG) database in the UK, ablation was the most commonly used technique for endometriosis. Excision was considered effective but less safe than ablation.22

Nd:YAG laser

Large deposits

Some of the benefits of laparoscopic surgery with laser, compared to other types of energy, include precision, and its ability to aid in quick healing, and cause less pain, discomfort, scarring, adhesions and tissue damage.

Many studies have reported that laser surgery would be beneficial in minimal-to-moderate endometriosis and may not be suited for treating severe forms. However, in a 2009 retrospective cohort study, Meuleman et al indicated that laparoscopic CO2 laser excision of deeply infiltrating endometriosis (colorectal) may help in improving the quality of life, pain, and sexual activity with low rates of complication and recurrence.25

With no established cure for endometriosis, extensive research is being conducted in an attempt to expand the spectrum of endometriosis treatment. More recently, ultrasound-guided high-intensity focused ultrasound (HIFU) ablation was found to be a promising therapeutic approach for endometriosis management. Owing to its non-invasiveness and other advantages such as reduced hospitalization time and low complication rate, HIFU is also considered as a therapeutic option for other conditions like adenomyosis, and tumours of prostrate, kidney, breast, uterus, pancreas, liver, soft tissue, etc.23

A retrospective investigation of the long-term outcomes of ablation with laparoscopic laser in infertile women having endometrioma, by Shimizu et al, demonstrated the overall long-term pregnancy rate, combining both spontaneous and IVF pregnancies, to be good (75.6%).26 Further, the ovarian reserve was not adversely affected by the surgery as demonstrated in patients opting for subsequent IVF cycles. However, currently, there is lack

The success of ablation depends on the skill of the surgeon to judge if all of the diseased part has been ablated. However, further investigation of the diseased tissue may not be possible if it is destroyed during

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of evidence to indicate the superiority of laser surgery over other methods in endometriosis treatment.

the superficial implants • Drainage of small cysts, which are <3 cm, followed by coagulation or vaporisation of the cyst wall lining • Drainage, coagulation or excision of large cysts which are >3 cm. Many trials have suggested the superiority of excision over the other two techniques in patients with large cysts owing to improved results with respect to pain, fertility and recurrence

Robot-assisted Laparoscopic Technique: Several studies have demonstrated the safety and feasibility of robotassisted procedure during gynaecological surgery.27 A 2008 review by Eltabbakh and Bower highlighted some of the key advantages of robotic-assisted laparoscopic surgery such as 3D view, low surgeon’s fatigue, and increased precision and dexterity, in the treatment of severe endometriosis.28 Some of the limitations are system bulkiness, high cost, big diameter instruments, and lack of vaginal access and tactile feedback.27

Adhesions: Scissors, laser beam or heat guns are used to remove adhesions linked to endometriosis but there is an increased risk for recurrence of the adhesions.9 Currently, there is a lack of preventive methods and fool-proof prophylactic methods that can be used during surgery to reduce adhesion formation.31

A more recent retrospective cohort controlled study reported similar results with both robot-assisted and standard laparoscopic techniques in the treatment of endometriosis. However, the researchers also noted that the robotic surgery required more anaesthesia and surgical time, besides the need for large diameter trocars and high costs.29

Adjuvant Surgical Treatment Modalities Techniques such as laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy (PSN) have been performed for intractable chronic pelvic pain associated with endometriosis. In LUNA, the uterosacral ligaments are transected to reduce pain, which therefore theoretically improves the long-term efficiency of laparoscopic endometriosis excision. The technique has not gained popularity as there is no concrete evidence for its effectiveness. In a 2010 meta-analysis of randomised studies, the researchers did not find any benefit in terms of decrease in chronic pelvic pain with LUNA.32 Similarly, a 2009 randomised controlled trial by UK researchers found that LUNA did not improve dysmenorrhoea, pain, quality of life, or dyspareunia in women with chronic pelvic pain when compared to laparoscopy without pelvic denervation.33 Davis and McMillan, in their 2003 review, suggested that the technique is not advocated in patients with normal-appearing uterosacral ligaments, but excision may be considered in deeply infiltrating endometriosis on the ligaments.7

Since the use of robotic technique is still in its infancy, more prospective studies are required to compare its effectiveness with conventional laparoscopy, which would help in arriving at a consensus on its applications.27 This may also help in answering some questions related to training, costs, privileging, and credentialing of the robotic technique.30

Choice of Surgical Technique Based on the Disease Endometriosis can present in different ways, which determines the type of surgery.

Endometrial Implants: Two techniques are generally used to treat endometrial implants: excision and coagulation. During excision, the entire implants are removed using scissors, laser, or very fine heat gun, following their separation from the surrounding normal tissue. If necessary, the excised implant can then be sent for biopsy in order to confirm the pathology. In the coagulation procedure, a fine heat gun or laser is used to burn or vaporise the implants. Comparative studies have demonstrated the higher effectiveness of excision since the chances of accidental damage of the underlying tissues/organs are more with coagulation.9

Laparoscopic presacral neurectomy involves the disruption of the hypogastric plexus for relieving chronic pelvic pain and dysmenorrhoea.7 Although a prospective randomized double-blind controlled study found that PSN improves the cure rate in women with endometriosisassociated dysmenorrhoea following conservative laparoscopic surgery,34 ASRM’s 2008 Practice Committee report emphasised that the procedure is technically challenging and may be linked to significant bleeding risk from adjacent venous plexuses.35 Yeung et al, in 2009, comprehensively reviewed literature on the laparoscopic treatment of endometriosis and concluded that PSN, and

Endometriomas: The treatment varies depending on the size and type of lesion.9 • Coagulation or vaporisation is performed to destroy

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not LUNA, to be a useful adjunctive tool to conservative surgery in patients with midline component of pain.36 Currently, there is insufficient evidence to recommend the use of adjunct surgical therapeutic interventions for the treatment of endometriosis.6

is ongoing debate on the preferred surgical management technique for endometrioma.12 A 2003 review by Dubuisson indicated that operative laparoscopy surgery could be the ‘gold standard’ treatment for endometrioma. Additionally, the review suggested/noted the following:42 • Need for peritoneal lavage cytology prior to cystectomy • High risk for recurrence if pseudocapsule is not excised when endometriomas are coagulated or laser vaporised • Repeat ovarian surgery may deplete the ovarian reserve, hence is not advocated in infertile women

Comparative Studies Treatment varies depending on the nature and extent of the disease. Comparative studies may aid physicians in identifying the optimum treatment strategy for managing diverse clinical scenarios.

Endometriotic Deposits: In 2009, a Cochrane review suggested that laparoscopic surgery was more effective than diagnostic laparoscopy alone in managing endometriosis-associated pelvic pain. However, there is lack of sufficient evidence to support the use of a particular laparoscopic surgical option over the other.37 A more recent Cochrane review also indicated that laparoscopic surgery could aid in improving future fertility in terms of improving the rates of clinical pregnancy, ongoing pregnancy, and live birth in patients with subfertility associated with minimal-to-mild endometriosis.38

Ovarian tissue damage and premature ovarian failure in young individuals are commonly associated with surgical treatment of ovarian endometriomas. In order to circumvent these disadvantages, Muzii and Panici in a 2010 study suggested a promising approach that involved both cyst excision and ablation, in which the latter technique can be used for ovarian hilus region to retain normal ovarian tissue and vascularisation. The modified technique was found to be safe and feasible without adversely affecting the ovary.43

Many studies have compared the effectiveness of different surgical techniques with varied results. A 2010 retrospective analysis published in the European Journal of Obstetrics & Gynecology and Reproductive Biology evaluated the effectiveness of the two laparoscopic techniques, coagulation and excision in the treatment of intraperitoneal superficial endometriosis.39 The researchers found that bipolar electrocoagulation provided better outcomes than excision in terms of lesser number of endometriosis-related symptoms and relapses. However, there is need for more prospective studies to validate the findings since the results were based on a retrospective non-randomized study. In a 2010 prospective randomised double-blind study, Healey et al did not find any substantial variation in pain reduction between patients who underwent ablation and excision of endometriosis.40

Disadvantages of Surgery There is evidence in literature that surgical treatment alone or in conjunction with medications is commonly used to treat all stages of endometriosis. However, the high recurrence rates associated with surgical excision of endometriotic implants may warrant the need for repeat medical treatment.44 Generally, the complications of surgery are observed more during treatment of deeply infiltrating endometriosis, especially on the probable negative effect on spontaneous fertility.45 This underscores the need for counselling patients on the potential complications including the repercussion on future fertility. They also have to be educated that surgery does not always provide relief from endometriosisassociated pain symptoms.45 Some of the limitations associated with surgical approach include8 • Risk of anaesthesia complications • Difficulty in identifying endometriosis during surgery • Difficulty in removing the lesions if they are close to vital structures in the fear of injuring the organs • Recurrence of endometriosis • High chances of further adhesions

Cysts: Alborzi in a 2004 prospective randomised clinical study concluded laparoscopic cystectomy to be a better option in comparison to coagulation and fenestration for achieving increased pregnancy rates, decreased recurrence and reoperation rates.41 Although drainage or excision of cyst capsule or electrocoagulation of the cyst wall are the commonly adopted procedures, there

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December 2010-January 2011

International Guidelines Based on the available scientific evidence, various organisations have issued guidelines for the management of endometriosis; some of those related to surgical therapy are listed below.

Organisations (Year) ASRM (2006 and 2008)2, 35

Guidelines Infertility • Ablation or excision of endometriotic lesions should be considered while performing laparoscopy • Laparoscopy and probably laparotomy may be advocated for stage III/IV endometriosis-associated infertility patients Pelvic Pain • Treatment selection should be individualised as both medical and surgical interventions are effective • Visible endometriotic lesions have to be excised or ablated in patients with pelvic pain • Longer relief from symptoms is achieved if endometriosis is treated with surgery followed by medications as opposed to only surgery • Definitive treatment such as hysterectomy and bilateral salpingo-oophorectomy has to be considered only for patients with debilitating symptoms, which can be ascribed to endometriosis. Also, such women should have completed childbearing and be non-responsive to alternative treatments

ESHRE (2008)*46

Pain • Ideal practice involves the surgical removal of endometriosis during laparoscopic diagnosis itself with prior preoperative patient consent • Pain associated with endometriosis may be reduced at 6 months by the combination of ablation and LUNA in patients with mild-to-moderate disease, when compared to diagnostic laparoscopy • Lack of evidence to substantiate LUNA as a key component in improving the pain • LUNA does not have any effect on dysmenorrhoea linked to endometriosis • Lesions have to be removed completely in severe and deeply infiltrating endometriosis to decrease the pain • Entire visible endometriosis has to be removed during hysterectomy (if it is needed) • Bilateral salpingo-oophorectomy may improve pain relief and decrease future chances of surgery Infertility • Ablation in addition to adhesiolysis may be effective in improving fertility in patients with minimal-to-mild endometriosis than diagnostic laparoscopy • Lack of meta-analyses and randomised controlled trials to verify if surgical excision improves pregnancy rates in moderate-to-severe endometriosis • Probable negative association between endometriosis stage and spontaneous pregnancy rate following surgical removal • Laparoscopic cystectomy in comparison to drainage and coagulation enhances fertility in ovarian endometriomas of diameter more than 4 cm Ovarian endometrioma • Laparoscopic ovarian cystectomy should be performed in patients with ovarian endometrioma ≥4 cm to histologically confirm the diagnosis, enhance follicular access, decrease infection risk and enhance ovarian response. However counselling patients on the probable risks such as low ovarian function post surgery and ovary loss is vital • Ovarian response may decrease with no cycle outcome improvement if laparoscopic ovarian cystectomy is performed prior to IVF/ICSI in subjects with unilateral endometriomas between 3-6 cm • High cyst recurrence risk if the pseudo capsule is not excised following coagulation or laser vaporisation of endometriomas

Collège National des Gynécologues et Obstétriciens Français (CNGOF; 2006)45

• Preferable to treat endometriosis at the time of diagnosis; however, if the lesion is associated with increased surgical risks, it would be better to defer the management after completing the workup • Surgical excision is not recommended during emergency laparoscopy (for cyst complications, adnexal torsion and suspected salpingitis) on identification of the lesions incidentally Pain • Surgery is effective in symptomatic endometriosis patients if the individual risk-to-benefit ratio is advantageous • Lack of evidence with respect to the comparison of effectiveness between medical and surgical treatment in the medium and long term • Total hysterectomy with bilateral salpingo-oophorectomy and excision of implants may be beneficial for recurrent pain Infertility • First-line treatment: If surgery can be performed during laparoscopy, it is likely to increase fertility. However, the same conclusions cannot be drawn in deeply infiltrating endometriosis. It is recommended to perform IVF directly without surgery if extensive lesions (which are associated with increased risk of surgical complications) are observed during laparoscopy • Second-line treatment: Better to wait for 6-12 months prior to initiating new treatment following satisfactory surgery if there are no risk factors; timeframe could be modified based on other factors such as age, subfertility, etc. If infertility persists after the surgery and is the only reason for repeat surgery, then it is not advised.

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Organisations (Year)

December 2010-January 2011

Guidelines Pain and Infertility • Repeat surgery is not recommended (need to be avoided if possible) if there exists a relationship between infertility and recurrent pain post initial surgical therapy Choice of approach • Laparoscopy is the preferred technique for the treatment of ovarian endometriomas and superficial peritoneal endometriosis Endometriotic cysts of ovary • Laparoscopic cystectomy superior to drainage and cyst wall destruction using bipolar coagulation for endometriomas of at least 3 cm • Oophorectomy could be considered as an alternative approach to cystectomy only in patients who do not desire pregnancy and have experienced a recurrence Deep infiltrative endometriosis • Excision helps in relieving pain during the medium-term follow up; however, the long-term results are not known • Partial cystectomy is good for deep infiltrating endometriosis lesions involving the bladder wall, whereas transurethral resection is not recommended Adjuvant surgery • LUNA is not recommended for the treatment of painful endometriosis • Lack of sufficient evidence regarding the effectiveness of presacral neurectomy for painful endometriosis • Adhesion barriers during surgery may aid in preventing pelvic adhesion reformation

*

The guidelines issued by Royal College of Obstetricians and Gynaecologists (RCOG) in 2006 are similar to those proposed by ESHRE.47

A 2008 report by ESHRE stated that laparoscopy can be performed on almost all patients with several benefits such as low morbidity, cost, and postoperative adhesion risk. Furthermore, laparotomy is advocated only in subjects with advanced stage endometriosis who cannot undergo laparoscopic surgery. Although definitive, radical procedures like oophorectomy and hysterectomy are to be employed only in severe disease. The extirpation of the cervix should be performed in hysterectomy as the pain may persist otherwise, especially in endometriosis of the cervix or utero-sacral ligaments.46

02. Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility. Fertil Steril. 2006 Nov;86(5 Suppl 1):S156-60.

03. ESHRE guideline for the diagnosis and treatment of endometriosis.

ESHRE. Last accessed January 19, 2011.

04. Treatments for endometriosis. endometriosis.org. Last accessed January 19, 2011.

05. Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician. 1999 Oct 15;60(6):1753-62, 1767-8.

06. Bedaiwy MA, Liu J. Pathophysiology, diagnosis, and surgical management of endometriosis: A chronic disease. srm. 2010 Aug;8(3):4-8.

Conclusion

07. Davis CJ, McMillan L. Pain in endometriosis: effectiveness of

There is still no consensus on the optimum strategy for treating endometriosis. Advancements in the field of minimally invasive field of surgery have led to safer and better surgical management of endometriosis. Evidence has shown that laparoscopic ablation for superficial disease and excision for deeply infiltrating endometriosis offers superior results, based on which many of the reviews suggest that laparoscopy should be considered as the ‘gold standard of care.’ However, it is critical that the treatment should be individualised based on the patient’s symptoms, age, family history, endometriosis stage, duration of infertility, and desired outcome measures such as recurrence prevention, fertility improvement and pain relief.21, 48

medical and surgical management. Curr Opin Obstet Gynecol. 2003 Dec;15(6):507-12.

08. Premkumar, G. Role of Laparoscopic Surgery in Endometriosis Associated Infertility—Literature Review. World Journal of Laparoscopic Surgery. January-April 2008;1(1):9-15.

09. Operative procedures for endometriosis. endometriosis.org. Last accessed January 19, 2011.

10. Nácul AP, Spritzer PM. Current aspects on diagnosis and treatment of endometriosis. Rev Bras Ginecol Obstet. 2010 Jun;32(6):298307.

11. Roman JD. Surgical treatment of endometriosis in private practice: cohort study with mean follow-up of 3 years. J Minim Invasive Gynecol. 2010 Jan-Feb;17(1):42-6.

12. Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database

References

Syst Rev. 2008 Apr 16;(2):CD004992.

01. Diagnosing endometriosis. endometriosis.org. Last accessed January 19, 2011.

www.endometriosis.in

More references available online

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INTERVIEW Minimally Invasive Surgery for Endometriosis Dr. Shylaja B. Rajiv, Assistant Editor, Endometriosis NEWS. Direct! interviews Dr. Tal about a clinician’s perspectives on surgical managment of endometriosis.

Q: Laparoscopy is considered as the ‘gold standard’ for the definitive diagnosis of endometriosis. Is there a sense that there is an increase in the number of unnecessary diagnostic laparoscopies and do you think there is any scope for reducing the same without missing the diagnosis?

A: In my own practice, I will often consider a trial of empirical treatment of suspected endometriosis without confirming the diagnosis by laparoscopy. If the patient is happy with this management and the possible uncertainty, then I consider it to be perfectly acceptable. For example, ‘The Pill’ for dysmenorrhea is fine if it works quickly and effectively, but persistent symptoms should be investigated further with a laparoscopy. Nevertheless, there has been a lowering of the threshold to perform laparoscopy since it is perceived to be increasingly safe and effective. In my experience, I do not think that unnecessary laparoscopies are increasing, but surgery should always be undertaken with a clear goal in mind and a justification for the procedure that can be sustained, regardless of the outcome. Not finding endometriosis can be just as important as finding it.

Dr. Tal Jacobson MA MRCOG FRANZCOG Sr. Lecturer, University of Queensland, Staff Specialist, Mater Mothers’ Hospital Department of Obs and Gyn, Aubigny Place, Raymond Terrace, South Brisbane, Australia

Q: Can you please explain briefly the basis of surgical management of the different stages of endometriosis? How often do you do bowel resection and what is the acceptance of such surgery in Australia and New Zealand?

A: All surgery planning depends on the underlying concerns of the patient and may also vary depending on whether pain or fertility is the specific concern.

The underlying basis of the surgical management of endometriosis is to remove disease and restore anatomy. Surgical management of Stage I and II disease is usually straightforward with the excision of peritoneal endometriosis and the removal of adhesions. Stage III and IV requires the same principles but with a greater focus on restoration of anatomy and full excision of deep endometriosis.

According to the Cochrane systematic review evidence, endometriomas are best excised, rather than ablated. Full excision of stage I and II endometriosis is usually advocated, but there is significant evidence that ablation alone or incomplete excision provides very similar outcomes.

I am reasonably conservative in my recommendations for bowel resection and will usually perform less than 20 per year. The operation is well accepted and has a good outcome, but requires extensive preoperative counseling to ensure that patients are aware of the alternatives, likely outcomes and potential complications, and allow them to make an informed decision about whether or not to proceed to surgery.

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Q: In your clinical experience, what is the recurrence rate of endometriosis following surgery? Do you always counsel your patients regarding recurrence?

A: The recurrence rate is not zero but if full excision is achieved, the rate is probably less than 10%. I usually counsel patients that about 80% of women will get some benefit from surgery but that pain may persist or fertility may not be achieved.

Q: If you were asked about the limitations of laparoscopic surgery in the management of endometriosis, what would you list?

A: The common limitations would be: • An acute abdomen secondary to rupture of massive endometriomas with a frozen pelvis where the diagnosis is unclear on admission and malignancy needs to be excluded.

• Complex severe endometriosis involving bowel and or ureters where there is no multidisciplinary laparoscopic team approach aimed at maximising the outcome for the patient.

Q: With the availability of different laparoscopic tools such as laser and electrocautery, what forms the basis of selecting a particular type of energy source?

A: Personally, I prefer standard monopolar diathermy on a hook and bipolar graspers (Maryland type). Products such as Ligasure or Gyrus have some potential advantages but are fairly expensive. I am increasingly using the harmonic scalpel which is good for dissection and cutting although it is less efficient in sealing vessels. The most important issue in choosing an energy source is that the surgeon must have a thorough understanding of the mode of action, use, and complications of the device.

Q: Although there is lack of sufficient evidence, hysterectomy with bilateral salpingooophorectomy are considered as definitive treatment of endometriosis.

Kindly let us know your views on this.

A: Although current practice is to avoid hysterectomy and to preserve the tubes and ovaries, there is evidence that hysterectomy prevents recurrence and provides long term pain relief and better quality of life. It may be that in order to fully excise all the endometriosis, any disease that is adherent to or ‘invading’ the uterus should also be removed, and this may be possible only by hysterectomy.

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December 2010-January 2011

Q: What is the effectiveness of laparoscopic uterosacral nerve ablation (LUNA) and presacral neurectomy (PSN) in endometriosis treatment? Is it always considered in patients who do not respond to conservative treatment?

A: Several studies have shown that LUNA has no benefit for secondary dysmenorrhea. If the surgery involves excision of endometriosis that is already on the uterosacral ligaments and therefore LUNA is a consequence of excision, then that may be a reason to undertake the procedure. Conversely, laparoscopic PSN is effective for the pain of endometriosis, but the complication rate is very high, and significant complications such as bleeding, constipation, painless labour and backache mean that PSN should only be undertaken by surgeons who carefully audit their outcomes and are prepared to justify these complications if they occur.

Q: How effective are adhesion barriers during surgery for endometriosis in preventing the pelvic adhesion reformation? What is your experience and is there any recommendation regarding the choice of products and also the method of use?

A: There is some evidence of a decrease in numbers of adhesions at second look laparoscopy with the use of adhesion barriers, but there is no evidence of any clinical difference such as decreased pain or improved fertility.

More studies are needed in this regard. I have used number of different products but generally I prefer to use Adept, which is 4% Icodextrin solution that can also be used intra operatively for irrigation. It is easily applied to the pelvis at the end of the procedure. It does tend to leak out through the port sites and can cause vulval oedema.

The FDA advise that it should not be used at laparotomy or if a bowel resection or appendicectomy is performed, due to the risk of sepsis.

Q: Please let us know your opinion on the interesting debate on the timing of reproductive surgery, i.e., if it has to be performed before IVF or after a failed cycle.

Will surgery for endometriosis prior to ART enhance the chances of success of treatment?

A: This is certainly an interesting debate. Most would agree that endometriomas greater than 3cm should be treated surgically prior to IVF. Significant pain symptoms may also lead to surgery prior to IVF. It may enhance ART success and also allow the chance of spontaneous

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conception prior to IVF. In many countries, including Australia, the funding arrangements may favour ART prior to surgery, even in cases where the converse may be the best clinical choice.

Q: Does ART increase cumulative recurrence rate of endometriosis? If so, how?

A: Although a theoretical argument could be made that FSH stimulation leading to higher estrogen levels can promote endometriosis, I am not aware of any evidence to suggest this occurs in practice. It is also not my experience that this occurs.

Q: What is the role of robotic surgery in the treatment of endometriosis? Is there a definite advantage?

A: Robotic surgery has been shown to have the same advantages as conventional laparoscopic surgery for endometriosis, such as shortened hospital stay, less analgesia and faster return to work, but the operative time is longer, the port sites are larger and the costs are much higher. There may be a specific role for the robot in the treatment of endometriosis requiring ureteric reanastamosis, but there is little evidence available at present. I am confident that as robots become smaller, lighter and cheaper, these factors will start to swing in favour of the robot.

December 2010-January 2011

management, provide training for young surgeons or perhaps identify centres of excellence?

A: The prevalence of endometriosis appears to be increasing. This may be due to some or all of the following factors; increasing recognition by patients that they have endometriosis leading to earlier referral and diagnosis, increasing recognition of the disease by gynaecologists, later childbearing, increased environmental toxins, and dietary changes. There are a number of challenges facing any organisation looking to provide the best care for women with endometriosis. A Centre of Excellence should aim to provide the best medical and surgical care in conjunction with a multidisciplinary approach, access to fertility treatment, a dedicated theatre team, an evidence-based approach and the collection of audit data.

Succession planning with training for future specialists is an important part of the role of a Centre of Excellence.

References 01. Ford J, English J, Miles WA, Giannopoulos T. Pain, quality of life and complications following the radical resection of rectovaginal endometriosis. BJOG. 2004;111:353–356.

02. Williams SK, Leveillee RJ. Expanding the horizons: robot-assisted reconstructive surgery of the distal ureter. J Endourol. 2009;23:45761.

03. Nezhat C, Lewis M, Kotikela S, Veeraswamy A, Saadat L, Hajhosseini B. Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril. 2010.

Q: Lastly, please give us some insights regarding endometriosis in your patient population, and how your organization is gearing up to manage it? Are there any proposals to issue guidelines regarding the

04. Jacobson TZ. Endometriosis Centres of Excellence - developing a consensus definition. World Endometriosis Society e-Journal.

2009;11(3):5-7.

Dr Tal Jacobson MA MBBS MRCOG FRANZCOG, is a Staff Specialist in Obstetrics and Gynaecology at the Mater Mother’s Hospital, Brisbane, Australia and a Senior Lecturer at the University of Queensland. Tal specialises in the management of endometriosis, pelvic pain, fibroids, infertility and menstrual disorders. He is an examiner for the RANZCOG membership. He was a Senior Lecturer and Consultant at the University of Auckland, New Zealand from 2004 to 2010. He trained in the UK at Cambridge, Oxford and London, completing a Fellowship in minimal access (keyhole) gynaecological surgery at St Bartholomew’s and the Royal London Hospitals. His original research on endometriosis, pelvic pain, infertility, and techniques of safe laparoscopic surgery has been published in peer reviewed journals and presented at international conferences. He has been awarded several prizes and awards for his minimal access surgery research.

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December 2010-January 2011

FEATURED MINI REVIEW New Evidence Validates Non-contraceptive Use of LNG-IUS for Endometriosis Management The efficacy and safety of levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena® | Bayer HealthCare) as a long-term contraceptive strategy has been well established through several studies. Two recent reviews and clinical trials have provided fresh evidence regarding the potential efficacy of the device in managing various gynaecological conditions including endometriosis.

A review by Rodriguez and Darney has offered substantial evidence to validate the non-contraceptive application of LNG-IUS in managing endometriosis, menorrhagia, adenomyosis, uterine fibroids and endometrial hyperplasia. Another review by Bednarek and Jensen reported that the IUS use is gaining wider acceptability for both contraceptive and non-contraceptive use. The two reviews have been published in the recent issue of the International Journal of Women’s Health.

The key non-contraceptive health-benefits of LNG-IUS, listed in a review by Frazer et al (Contraception, 2010), are as follows: • Reduction in menstrual bleeding and dysmenorrhoea • Long-term prevention of many gynaecological conditions including endometriosis, endometrial hyperplasia, acute episodes of pelvic inflammatory disease and uterine fibroids • Treatment of menorrhagia linked to adenomyosis, endometriosis, endometrial hyperplasia and uterine fibroids

Several studies have also validated the role played by LNGIUS in alleviating endometriosis-associated pelvic pain. In one such study, Petta et al (Human Reproduction, 2005) concluded that the device could be a potential therapeutic option for managing chronic pelvic pain in subjects not opting for conception. The randomised clinical trial also highlighted the following additional benefits of LNG-IUS: • Comparable efficacy with that of GnRH-analogue for treating chronic pelvic pain • Non-induction of hypoestrogenism • Single medical intervention for the implantation of the device every five years A review by Anpalagan and Condous (Journal of Minimally Invasive Gynecology, 2008) has suggested that the reduction in blood flow in the subendometrial spiral and uterine arteries conferred by LNG-IUS insertion, as the possible rationale for alleviating primary dysmenorrhoea.

Additionally, the study had concluded on the use of the device as a potential substitute to repeat laparoscopic surgery, particularly in women suffering from persistent symptoms even after laparoscopic excision of endometriosis.

The consolidated evidence of the recent reviews and clinical trials underscore the need for developing consensus to clearly define the patient population benefiting the most from the use of such intrauterine progestin-eluting devices.

References

A recent randomised controlled trial by Wong et al (The Australian and New Zealand Journal of Obstetrics and Gynaecology, 2010) concluded on the efficacy of the system in achieving symptomatic control of endometriosis and prevention of its recurrence following conservative surgery. The study also reported better patient compliance and bone gain in the LNG-IUS group, when compared to patients who had undergone treatment using depot medroxyprogesterone acetate once in three months for a period of three years.

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01. Rodriguez MI, Darney PD. Non-contraceptive applications of the levonorgestrel intrauterine system. Int J Womens Health. 2010 Aug 9;2:63-8.

02. Bednarek PH, Jensen JT. Safety, efficacy and patient acceptability of the contraceptive and non-contraceptive uses of the LNG-IUS. Int J Womens Health. 2010 Aug 9;1:45-58.

03. Fraser IS. Non-contraceptive health benefits of intrauterine hormonal systems. Contraception. 2010 Nov;82(5):396-403.

More references available online

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December 2010-January 2011

MINI REVIEWS Introital 3D Transvaginal Sonography Effective in the Preoperative Diagnosis of Rectovaginal Septal Endometriosis With laparoscopy being invasive and clinical examinations lacking the accuracy in determining the exact location and extent of deeply infiltrating endometriotic (DIE) lesions, non-invasive imaging processes could be vital during preoperative work-up for DIE diagnosis. Results from a prospective study published in the journal Fertility and Sterility, has indicated that introital 3D transvaginal ultrasonography (3DUS) may be an effective technique for diagnosing rectovaginal septal endometriosis.

of MR (76.4% and 100%). The scientists concluded that MRI was a reliable method for diagnosing DIE, while ultrasonography was good for deep lesions at specific locations.

Some of advantages and limitations of the highly reproducible 3DUS technique are as follows: Advantages

Limitations

Maria Angela Pascual, from the Department of Obstetrics, Gynecology, and Reproduction, University of Barcelona, Spain, and coworkers, conducted the study to assess the accuracy of introital 3D transvaginal sonography in diagnosing rectovaginal septal endometriosis before the surgery. The sonographic results of the 39 subjects suspected with rectovaginal septal endometriosis, obtained prior to laparoscopic radical resection, were compared with surgical and histological findings.

• Enables reconstruction of • 3D transducer manipulation is target image after a single complicated as they are bigger sweep of ultrasound beam than 2D transducers across the organs • Difficult to archive data and • Provides unhindered access to communicate due to the bulky innumerable viewing planes 3DUS information • Allows interpretation and • Requires skilled and review of volumetrically experienced operator acquired sonographic data • Allows numerous viewing • May be associated with a time lag between image acquisition algorithms to display the and display data with various techniques

After surgery and histopathological investigation, 19 patients were confirmed with deep rectovaginal septum endometriosis. The study results indicating the variables of introital 3D transvaginal sonography are listed in the table below.

enhanced • Facilitates evaluation of the nodules by making its asymmetrical borders and shapes more evident

Variables

Value

95% CI

Specificity Sensitivity Positive likelihood ratio Negative likelihood ratio

94.7% 89.5% 17.2 0.11

78.6%-99.7% 73.3%-94.5% 2.51-115 0.03-0.41

Based on the study findings, the researchers suggested the inclusion of introital 3D transvaginal ultrasonography as part of preoperative work up for diagnosing deep endometriosis in suspected patients.

such as volume rendering, multiplanar reformatting and surface rendering

Although laparoscopy is the gold standard for diagnosing endometriosis, it may not always detect deep endometriosis present in subperitoneal space and those covered by adhesions. Now, with the current study indicating positive results for introital 3D transvaginal sonography, it holds promise as a probable preoperative imaging modality for DIE diagnosis.

References 01. Pascual MA, Guerriero S, Hereter L, et al. Diagnosis of endometriosis of the rectovaginal septum using introital three-dimensional

In another recent study, Grasso et al (Abdominal Imaging, 2010) compared the potential of transvaginal 3DUS and magnetic resonance (MR) in preoperatively defining the extent of deeply infiltrating pelvic endometriosis. The researchers found that the sensitivity and specificity of transvaginal 3DUS (76.9% and 100%) in diagnosing rectovaginal septal endometriosis were similar to that

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ultrasonography. Fertil Steril. 2010 Dec;94(7):2761-2765.

02. Grasso RF, Di Giacomo V, Sedati P, et al. Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography. Abdom Imaging.

2010 Dec;35(6):716-725.

More references available online

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December 2010-January 2011

Better Survival Rates for Endometriosis-associated Ovarian Cancer Compared to Ovarian Cancer A recent retrospective study published in the American Journal of Obstetrics and Gynecology has reported better survival rates for endometriosis-associated ovarian cancer (EAOC) compared to ovarian cancer (OC) itself; probably due to the increased prevalence of low-grade and earlystage tumours in EAOC. Sanjeev Kumar, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, and coworkers, compared 42 EAOC patients (median age=52 years) with 184 OC cases (median age=59 years) to assess the prognosis of OC associated with endometriosis. The study results, demonstrating the higher prevalence of low-grade and early stage tumours, clear cell and endometrioid cell tumours, and the enhanced survival rates in EAOC group compared to OC subset, are listed below: • Median survival rate=199 vs. 62 months • Five-year survival rate=62% vs. 51%; P=0.38 • Low-grade tumours=21 % vs. 8%; P=0.04 • Early stage tumours=49% vs. 24%; P=0.002 (International Federation of Gynecology and Obstetrics I and II combined) • Clear cell tumours=21% vs. 2% • Endometrioid cell tumours=14% vs. 3% However, mucinous tumours were more prevalent in the OC group (P=0.001). After controlling for factors such as age, stage, grade, and treatment, the researchers also found that OC associated with endometriosis is not an independent predictor for the improved survival rates.

Clinical Oncology, 2009) reported that age (>40) and endometrioma size (>9 cm) were independent predictors of OC development in ovarian endometrioma patients.

The study augmented the need for further research on the pathogenesis, pathophysiology, and actual mechanism involved in the endometriosis progression, which may aid in the prevention of EAOC and also in identifying effective therapeutic strategies.

Studies have suggested that endometriosis may act as a precursor for OC, in particular for the endometrioid and clear cell subtypes; women with atypical endometriosis appear to be at a higher risk of developing EAOC. In 2008, the European Society of Human Reproduction and Embryology (ESHRE) suggested the following with reference to endometriosis and its association with cancer: • Although the transformation of endometriosis to cancer has been observed, it occurs very rarely • Estimated overall risk of cancer in women with endometriosis is 0.7 to 1.0%, indicating that in general, higher risk is not linked to the gynaecological disorder • Specific additional screening to identify cancer cannot be suggested owing to the lack of established screening techniques.

References 01. Kumar S, Munkarah A, Arabi H, et al. Prognostic analysis of ovarian cancer associated with endometriosis. Am J Obstet Gynecol. 2011 Jan;204(1):63.e1-7.

02. Lu Y, Liu MH, Zheng Y, Guo SW, Liu XS. Clinicopathological features of 67 cases of endometriosis-associated epithelial ovarian carcinoma

Similar findings were reported in several other studies (Lu et al; Zhonghua fu chan ke za zhi, 2009; Van Gorp et al; Best Practice & Research: Clinical Obstetrics & Gynaecology, 2004), wherein EAOC had low-stage distribution of tumours and showed improved survival rates compared to non-endometriosis-associated OC. The researchers also found these patients to be younger and typically diagnosed with clear-cell subtype.

[in Chinese]. Zhonghua Fu Chan Ke Za Zhi. 2009 Nov;44(11):832-6.

03. Van Gorp T, Amant F, Neven P, Vergote I, Moerman P. Endometriosis and the development of malignant tumours of the pelvis. A review of literature. Best Pract Res Clin Obstet Gynaecol. 2004 Apr;18(2):349-71.

04. Kobayashi H. Ovarian cancer in endometriosis: epidemiology, natural history, and clinical diagnosis. Int J Clin Oncol. 2009 Oct;14(5):378-82.

05. The ESHRE Guideline on Endometriosis 2008. ESHRE. Last accessed

A recent review by Kobayashi (International Journal of

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December 4, 2010.

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MINI REVIEWS

Laparoscopic Ureterocystoneostomy Offers Better Outcomes in Ureteral Endometriosis A study published in the recent issue of the journal Human Reproduction has reported that laparoscopic ureterocystoneostomy is feasible, with favourable outcomes at short- and medium-term follow-up in patients with intrinsic ureteral endometriosis.

Anna Stepniewska from the Department of Obstetrics and Gynecology, Ospedale Sacro Cuore Don Calabria, Italy, and co-researchers, observed 20 patients who had undergone ureterocystoneostomy for pelvic endometriosis, to assess the postoperative clinical outcomes and complication rates at one and six months follow up. Cystography was performed on the 7th day following the surgery to check if the bladder capacity was satisfactory, and the integrity of anastomosis was determined. The other measurements in the study included preoperative clinical and instrumental assessment, intra- and postoperative complications, pain improvement by visual analogue scale for endometriosisassociated symptoms, and uro-specific pain results.

The key postoperative findings are as follows: • Absence of ureteral fistula and other complications that needed re-intervention • Temporary deficiency of bladder voiding, pyrexia, and urinary infection reported in five (25%), four (20%) and one (5%) patient, respectively • Bladder voiding function resumed at a median time of 3 days (range=1-20 days) • Mild vesico-ureteral reflux at the operated side noticed in six patients using cystography • Significant improvement in all postoperative symptoms • Good postoperative reconstructions in all patients, as substantiated by cystography and urography done at 6 months

Similarly, an earlier study by Camanni et al (Reproductive Biology and Endocrinology, 2009) highlighted that ureteroneocystostomy was a better surgical option compared to ureterolysis in patients with severe hydronephrosis, severe stenosis and also those who are at a higher risk of intrinsic ureteral disease.

Ureteral endometriosis can cause ureteral obstruction and lead to hydroureter, dilatation of the renal pelvis and finally kidney failure. Patients with intrinsic ureteral endometriosis are usually associated with more severe stenosis and frequent hydronephrosis.

Previous studies have demonstrated that the surgical management of deeply infiltrating ureteral endometriosis is a difficult procedure, and requires a perfect balance between total endometriotic foci removal and prevention of morbidity related to radical surgery.

Owing to the rarity of ureteral endometriosis, not many studies have been conducted to validate the effectiveness of surgical treatment, as a result of which there is no clear accord on the optimal surgical approach for the condition.

Despite the current findings reporting the usefulness of laparoscopic ureterocystoneostomy in ureteral endometriosis, the researchers indicate the need for further studies to clearly establish its role and develop international consensus for the effective management of the condition.

References 01. Stepniewska A, Grosso G, Molon A, et al. Ureteral endometriosis: clinical

and

radiological

follow-up

after

laparoscopic

ureterocystoneostomy. Hum Reprod. 2011 Jan;26(1):112-6.

Based on the study findings, the researchers concluded that stenotic tract removal and maintenance of renal function were the main objectives of surgical treatment in ureteral endometriosis.

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02. Camanni M, Bonino L, Delpiano EM, et al. Laparoscopic

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conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis. Reprod Biol Endocrinol.

2009 Oct 12;7:109.

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December 2010-January 2011

Endometriosis Implicated in the Aetiology of Sacral Radiculopathies and Sciatica A recent prospective cohort study published in Fertility and Sterility suggests that patients with sciatic neuralgia and sacral radiculopathies (pudendal and gluteal pain) of unknown origin should be laparoscopically examined for endopelvic pathologies such as endometriosis or vascular entrapment.

Marc Possover and co-researchers from the Department of Surgical Gynecology and Neuropelveology, Hirslanden Clinic, Zurich, conducted the study on 213 women with sacral radiculopathies (pudendal, gluteal pain, sciatica) of unknown cause, to investigate the endopelvic cause of the disorder. The patients underwent laparoscopic exploration of sacral plexus followed by nerve decompression. The following results were obtained after laparoscopic management: • Isolated endometriosis of the sciatic nerve was reported in 27 patients • Presence of deep infiltrating parametric endometriosis with sacral plexus infiltration was noticed in 148 patients • Vascular entrapment of sacral plexus was noted in 37 patients • Pyriformis syndrome was observed in one patient • The following corresponding values of decrease in visual analogue scale pain scores were noted before and after surgery, during 6 months follow up: οο Patients with sacral plexus endometriosis showed 7.7 (± 1.16; range 6-10) and 2.6 (± 1.77; range 0-6) οο Subjects with vascular entrapment showed 6.6 (± 1.43; range 5-9) and 1.5 (± 1.27; range 0-4)

somatic nerve could be a treatment option for managing endometriotic infiltration of the sacral plexus.

Infiltration of retroperitoneal spaces by endometriotic tissue is considered to be one of the causes of sacral plexus lesions. Sciatic nerve can be compressed by endometriosis lesions in the pelvic region, within the sheath of the sciatic nerve, at the sciatic notch, or in the gluteal region distal to the notch. Some of the reasons suggested for the presence of endometrial tissue in the sciatic nerve area are • migration of endometrial tissue from genitals to sciatic nerve through the peritoneal diverticulum • retrograde menstruation across the fallopian tubes • migration of endometriotic tissue after vascular damage caused by injuries or surgery Endometriotic implants, on deposition, could compress the sciatic nerve or sacral plexus, generating pain that may extend from lower back to the toe. Pain relief and improvement in the neurological functions may be achieved through surgical excision of endometriosis and adhesions in and around the sciatic or sacral plexus nerves, and ovarian cycle suppression.

With several trials implicating endometriosis as one of the rare factors responsible for neurological conditions, such as sciatica and sacral radiculopathy, its early diagnosis and treatment may avoid irreversible damage to the affected nerve.

References

An earlier study by Possover and colleagues (Minimally Invasive Neurosurgery, 2007) suggested the infiltration of the lateral pelvic wall by endometriotic lesions to be one of the causes for unilateral pudendal neuralgia (Alcock’s canal syndrome) or chronic unilateral sciatica, where no neurological or orthopaedic cause was found. It was also indicated that laparoscopic neurolysis of the pelvic

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01. Possover M, Schneider T, Henle KP. Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertil Steril. 2010 Sep 24. [Epub ahead of print] 02. Possover M, Baekelandt J, Flaskamp C, Li D, Chiantera V.

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Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall. Minim Invasive Neurosurg. 2007 Feb;50(1):33-36.

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NEWS Central Sensitisation as Probable Mechanism for Endometriosisassociated Hyperalgesia A team of Chinese researchers have confirmed the occurrence of generalised hyperalgesia in endometriosis patients and surgery as an optimum strategy for alleviating such increased pain sensitivity. The study published in the journal Reproductive Sciences also proposes central sensitisation as a probable underlying mechanism for various forms of pain linked to endometriosis.

Weiwei He and co-workers from Shanghai Obstetrics and Gynecology Hospital, Fudan University, China, evaluated the hypothesis that generalised hyperalgesia is linked to endometriosis and also the impact of surgery in improving the symptom. The study was conducted on 100 subjects with surgically and histologically confirmed disease, and 70 disease-free subjects. The severity of dysmenorrhoea of all the subjects was rated prior to the surgery using visual analog scale (VAS). Both the groups were also subjected to ischemic pain test (IPT) and an electrical pain test (EPT) before the procedure to analyse their response to pain stimulation. The IPT and EPT tests were repeated three and six months after the surgery in all the patients.

The study results showed a substantially elevated IPT and VAS scores and reduced EPT pain threshold in the study group compared to the controls. Also, the study group was noted to have progressive and significant improvement in IPT scores and EPT pain threshold along with decrease in the severity of dysmenorrhea post surgery.

role in the development of newer therapeutic agents against endometriosis.

Central sensitisation occurs due to defective afferent input and the release of neuroactive substances in the dorsal horn of the spinal cord. This hyperexcitability is also linked to the augmented receptive field size of dorsal horn neurons and an enhanced facilitation of reflexes. An earlier study by Aslam et al (British Journal of Obstetrics and Gynaecology, 2009) reviewed the pathophysiology of visceral hyperalgesia and defined it as a pain state caused due to central and peripheral sensitisation. Some of the proposed factors contributing to the condition are as follows: • Temporal and spatial summation of pain stimuli • Long-lasting pain states • Chronic inflammation • Genetic factors The recent findings mandate extensive studies to identify the exact mechanisms that underlie the development of central excitability, and further interventional studies that focus on visceral hyperalgesia. The elucidation of these mechanisms holds paramount significance in developing newer strategies for effective management of endometriosis.

References 01. He W, Liu X, Zhang Y, Guo SW. Generalized Hyperalgesia in Women With Endometriosis and Its Resolution Following a Successful

Validating central sensitisation as a probable mechanism for pain associated with endometriosis, the research team concluded that its identification could play a major

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Surgery. Reprod Sci. 2010 Dec;17(12):1099-111.

02. Aslam N, Harrison G, Khan K, Patwardhan S. Visceral hyperalgesia

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in chronic pelvic pain. BJOG. 2009 Nov;116(12):1551-5.

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NEWS

Study Highlights the Effectiveness of Laparoscopy in Bladder Endometriosis Management Several studies have suggested a combination of transurethral resectoscopy and laparoscopy as an alternative to laparotomy in treating bladder endometriosis, particularly in women with concurrent pelvic endometriosis. Now, a recent retrospective study published in The Journal of Minimally Invasive Gynecology highlights that although laparoscopy has been effective in all types of bladder endometriosis, multiple procedures may be necessary for the management of related lesions, particularly rectovaginal nodules and ureteric lesions.

Elias Kovoor and colleagues from the Research Institute Against Digestive Cancer (IRCAD) and University Hospital of Strasbourg, France, conducted the study on 21 consecutive subjects, from a series of 169 patients, to demonstrate laparoscopic excision outcomes in deep bladder endometriosis. The primary outcome measures considered were resolution of bladder symptoms, while the secondary outcomes included complication, recurrence, and pregnancy rates.

All the patients underwent laparoscopy without any conversion to laparotomy and were followed up for a median of 20 months post surgery. Partial cystectomy was done for 10 subjects while the remaining were treated with partial-thickness excision of the detrusor muscle.

The study findings showed 16 patients (76%) with deep pelvic lesions, among which rectovaginal nodules (38%) and ureteric lesions (14%) with signs of obstruction were found to be commonly associated with bladder endometriosis. Major complications mainly linked to bowel resection were noticed in 3 patients (14%).

Pregnancy occurred in six subjects (60%) and none of the patients showed recurrence of disease.

complete laparoscopic excision of the disease resolved the bladder symptoms and reduced the recurrence rates.

The researchers suggested that there was no need for partial cystectomy in all cases for attaining adequate clearance.

The effectiveness of partial cystectomy in the treatment of bladder endometriosis has been demonstrated in earlier studies. A retrospective review by Antonelli et al (European Urology, 2006) reported that partial cystectomy provided long-lasting results in the treatment of bladder endometriosis. The researchers also suggested that laparoscopy should be adopted in patients with severe disease, needing multiple procedures, since radical surgery may be helpful in preventing recurrences.

In 2008, the ESHRE Special Interest Group (SIG) recommended the following guidelines for the treatment of bladder endometriosis: • Surgical therapy should generally involve the removal of endometriotic lesions and primary closure of the bladder wall.

• Removal of ureteral lesions may be done following ureter stenting. If there is significant obstruction or significant lesions, end-to-end anastomosis after segmental excision may be needed.

References 01. Kovoor E, Nassif J, Miranda-Mendoza I, Wattiez A. Endometriosis of bladder: outcomes after laparoscopic surgery. J Minim Invasive Gynecol. 2010 Sep-Oct;17(5):600-4.

02. Antonelli A, Simeone C, Zani D, et al. Clinical aspects and surgical treatment of urinary tract endometriosis: our experience with 31 cases. Eur Urol. 2006 Jun;49(6):1093-7.

03. Extragenital endometriosis. The ESHRE Guideline on Endometriosis

Based on the study findings, it was concluded that

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2008. ESHRE. Last Accessed October 4, 2010.

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NEWS

Identical Outcomes after Robot-assisted and Standard Laparoscopic Treatment of Endometriosis A retrospective cohort controlled study published in the journal, Fertility and Sterility reported good and similar results for robot-assisted and standard laparoscopic techniques in the treatment of endometriosis. However, the researchers concluded that the former needed extended anaesthesia and surgical time, and also largesized trocars compared to standard laparoscopy.

Camran Nezhat and colleagues from the Centre for Minimally Invasive and Robotic Surgery, Stanford University Medical Centre, California, conducted the study to compare the outcomes of the two techniques in endometriosis treatment. The study included 78 women of reproductive age, out of whom 40 underwent robotassisted surgery, while the remaining were treated with standard laparoscopy. Age, body mass index, previous abdominal surgery and stage of endometriosis were matched in both the groups. The mean operative time for robotic and standard laparoscopy was 191 minutes (range=135–295 minutes) and 159 minutes (range=85–320 minutes), respectively. No major variations in blood loss, intraoperative or postoperative complications, or hospitalisation time were noted between the two groups.

Also, the scientists did not observe any conversions to laparotomy.

Owing to the technological advantages of robotic surgery, many surgeons have supported its use in gynaecologic surgery. However, further prospective trials are needed to evaluate pain, complications, return to routine activity and long-term clinical outcomes associated with robotic surgery in comparison with standard laporoscopic and open approaches. Questions regarding the cost, training and privileging in robotic technology still remain unresolved. A earlier review by Kim et al (Yonsei Medical Journal, 2008) suggests the need for cautious assessment and confirmation of the robotic surgery’s advantages prior to its wide acceptance in the field of gynaecology.

References 01. Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril. 2010 Dec;94(7):2758-60.

02. Eltabbakh GH, Bower NA. Laparoscopic surgery in endometriosis.

Minerva Ginecol. 2008 Aug;60(4):323-30.

03. Kim YT, Kim SW, Jung YW. Robotic surgery in gynecologic field.

Yonsei Med J. 2008 Dec 31;49(6):886-90.

A review by Eltabbakh and Bower (Minerva Ginecologica, 2008), reiterated that robotic-assisted laparoscopic surgery is advantageous in the management of severe endometriosis. Some of the benefits and limitations associated with robot-assisted laparoscopic surgeries in gynaecology are listed in the table below Advantages

Disadvantages

• Three dimensional view of the operating area • Quick learning curve for suturing • Operating in sitting posture • Surgeon’s exhaustion and tension tremor reduced • Additional wrist motion to enhance dexterity • Short hospital stay • Few major complications compared to laparotomy • Improved surgical accuracy/ precision

• High cost • Increased operating times owing to the assembly and disassembly of bulky equipments • Diameter of the instruments (8 mm) • Limitation with respect to number of robotic arms

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