{"paper_id":"bd915daa-21b6-40f3-aca7-4e95820f537f","body_text":"Introduction\n!\nEndometriosis is one of the most common gynae-\ncological disorders but also one of the greatest\nchallenges facing gynaecological surgeons [1]. A\nguideline-oriented approach [2], extensive expe-\nrience of surgical techniques and interdisciplinary\ncooperation [3] are the prerequisites for success-\nful treatment.\nA detailed history of individual symptoms, ade-\nquate diagnostics and special surgical skills are in-\ndispensable for diagnosing endometriosis and for\npreoperative planning and surgery [4]. It is also\nimportant that the surgeon and patient take the\ntime to consider the “difficult”, in some instances,\ncontroversial, and potentially risky aspects of pos-\nsible surgical interventions.\nFactors to consider include individual risks, such\nas the risk of recurrence, as well as factors intrin-\nsic to the disease and the risks associated with the\nsurgical technique. This paper discusses several\nsuch combinations which deserve particular con-\nsideration due to their prevalence and potentially\nserious consequences.\nAbstract\n!\nEndometriosis is one of the most common disor-\nders encountered in surgical gynaecology. The\nlaparoscopic technique, the planning of the surgi-\ncal intervention, the extent of information pro-\nvided to patients and the interdisciplinary coordi-\nnation make it a challenging intervention. Com-\nplete resection of all visible foci of disease offers\nthe best control of symptoms. However, the possi-\nbility of achieving this goal is limited by the diffi-\nculty of detecting all foci and the risks associated\nwith radical surgical strategies. Thus, the excision\nof ovarian endometrioma can result in a signifi-\ncant impairment of ovarian function, while dam-\nage to nerve structures during resection of the\nuterosacral ligaments, the parametrium, the rec-\ntovaginal septum or the vaginal cuff to treat deep\ninfiltrating endometriosis can lead to serious\nfunctional impairments such as voiding disorders.\nA detailed risk-benefit analysis is therefore neces-\nsary, and patients must be treated using an indi-\nvidual approach.\nZusammenfassung\n!\nDie Endometriose gehört zu den häufigsten\nKrankheitsbildern in der operativen Gynäkologie\nmit erheblichen Herausforderungen an die lapa-\nroskopische Technik, aber auch die OP-Planung,\nPatientinnenaufklärung und Interdisziplinarität.\nZiel im Hinblick auf eine bestmögliche Symptom-\nkontrolle ist die vollständige Entfernung der er-\nkennbaren Krankheitsherde, die aber limitiert\nwird durch nachweisliche Grenzen der Detektier-\nbarkeit und die Risiken radikaler Operationsstra-\ntegien. So kann die Exzision ovarieller Endome-\ntriome zu einer signifikanten Beeinträchtigung\nder Ovarialfunktion, die Läsion nervaler Struktu-\nren bei der Resektion tief-infiltrierender Endo-\nmetriose der Sakrouterinligamente, der Parame-\ntrien, des Septum rectovaginale und des Vaginal-\npols zu schwerwiegenden Funtionsbeeinträchti-\ngungen wie Blasenentleerungsstörungen führen.\nEine gründliche Nutzen-Risiko-Abwägung muss\ndaher symptomorientiert erfolgen und in einem\nindividualisierten Vorgehen resultieren.\nSurgical Therapy of Endometriosis:\nChallenges and Controversies\nHerausforderungen und Kontroversen bei der operativen Therapie\nder Endometriose\nAuthors S. Rimbach 1, U. Ulrich 2, K. W. Schweppe 3\nAffiliations 1 Gynäkologie und Geburtshilfe, Landeskrankenhaus Feldkirch, Feldkirch, Austria\n2 Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin\n3 Endometriose-Zentrum Ammerland, Westerstede\nKey words\nl\" reproductive medicine\nl\" dyspareunia\nl\" endometriosis\nl\" gynaecology\nl\" infertility\nl\" ovary\nSchlüsselwörter\nl\" Reproduktionsmedizin\nl\" Dyspareunie\nl\" Endometriose\nl\" Gynäkologie\nl\" Infertilität\nl\" Ovar\nreceived 4. 8. 2013\nrevised 4. 9. 2013\naccepted 4. 9. 2013\nBibliography\nDOI http://dx.doi.org/\n10.1055/s-0033-1350890\nGeburtsh Frauenheilk 2013; 73:\n918–923 © Georg Thieme\nVerlag KG Stuttgart · New York ·\nISSN 0016‑5751\nCorrespondence\nPriv.-Doz. Dr. Stefan Rimbach\nLandeskrankenhaus Feldkirch\nGynäkologie und Geburtshilfe\nCarinagasse 47\n6800 Feldkirch\nÖsterreich\nstefan.rimbach@vlkh.net\n918\nRimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923\nGebFra Science\n\n\nExtent of Surgery and\nDealing with Unexpected Findings\n!\nBoth from the surgeon ʼs and the patient ʼs point of view, the ex-\ntent of the actual manifestation of disease and the associated ex-\ntent of the planned surgery are the most important preoperative\nconsiderations, but these are also the factors which are most dif-\nficult to assess preoperatively. Frequently, the extent of surgery\nwill only become clear intraoperatively.\nThe lines of resection are primarily determined by the extent of\ndisease spread. The goal of surgery is complete resection, which\ncan include resection of parts of the intestine and involve the\nureters and bladder [5 –11].\nIn addition to the necessary surgical experience, a good interdis-\nciplinary cooperation and close involvement of the patient are\nimportant during the planning stage. Despite adequate diagnos-\ntics, it may be necessary to broaden the scope of the primary in-\ntervention. This may also be unexpectedly necessary during sur-\ngery, for example, if there is intestinal involvement beyond the\nrectovaginal septum or non-obstructive involvement of the ure-\nter (l\n\" Fig. 1 a and b).\nThis not untypical constellation represents a considerable chal-\nlenge as regards the information routinely provided to the pa-\ntient preoperatively and for surgical logistics. The problem is\ncommonly tackled using one of two approaches: either a flexible\nsurgical strategy with the patient given a maximum of informa-\ntion about all eventualities or a two-stage approach compatible\nwith the disease constellation. It is important in every individual\ncase to weigh up the psychological burden for the patient which\nmay be affected by the amount of information given (which may\nbe far too extensive) and, depending on the structure of the hos-\npital department, the possibly unnecessary allocation of operat-\ning room capacity and interdisciplinary personnel resources\nagainst the disadvantages of a second operation.\nIn each case, clear positioning during preoperative planning is\nrecommended to guard against surprises.\nIn addition to the extent of endometriosis, secondary factors such\nas the presence of adhesions or, in the case of the retroperitoneal\nspace, the presence of fibrotic lesions also have a significant im-\npact on surgery. These factors can change the anatomy to such an\nextent that extensive dissection is necessary for reconstruction.\nIntestinal adhesiolysis and extensive ureterolysis may be re-\nquired to reach the endometriotic lesion and to avoid iatrogenic\ninjury to structures close to the margins of the endometriotic le-\nsion. At the same time, dissection is also associated with an in-\ntrinsic risk of injury.\nInjuries are by no means rare; in fact, they are fairly common,\nparticularly when treating deep infiltrating endometriosis, and\nrequire awareness and appropriate discussion preoperatively.\nLimits of Detectability of Endometriotic Lesions\nand Differentiation from Healthy Tissue\n!\nThe detection and differentiation of endometriotic lesions from\nhealthy tissue is a challenge ( l\" Fig. 2), particularly in cases of re-\ncurrence.\nOut of a total of 39 patients with persistence of complaints after\nexcision or ablation of histologically verified endometriosis, re-\npeat laparoscopy found peritoneal recurrence in 37 %. Recurrence\noccurred significantly more frequently in previously operated\n(RR 2.54; 95 % confidence interval [CI]: 1.63 –3.97) or immediate-\nly adjacent (RR 1.29; 95 % CI: 0.84 –2.0) areas compared to areas\ndistant to the original localisation, which supports the hypothesis\nthat primary resection was probably incomplete [12]. The reason\nfor this could be that endometriotic lesions in the peritoneum\ncan extend far beyond the visible foci, as has been shown in ex-\naminations using scanning electron microscopy [13]. The pres-\nence of residual foci of endometriosis in a number of patients\ncould also explain the success of a combined approach using sur-\ngery and hormone therapy. This interpretation is supported by\nthe results of a prospective randomised study in 450 patients\nwhich compared outcomes after surgery, hormone therapy or\ncombined surgery and hormone therapy. The combined ap-\nproach had significantly better results, with a 60 % success rate\nas measured by the clinical parameters “dysmenorrhea” and\n“dyspareunia” and findings at second-look laparoscopy, com-\nFig. 1 a and ba Involvement of the left ureter in a case with rectosigmoid\nendometriosis. b After ureterolysis and rectosigmoid resection.\nFig. 2 Peritoneal endometriosis with unclear extent and spread: red le-\nsions with typical vascular patterns next to fibrotic peritoneal defects.\n919\nRimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923\nDGGG Review\n\n\npared to rates of 55 % for exclusively hormone therapy and 50 %\nfor exclusively surgical treatment [14].\nRadical Dissection: Opportunities and Risks\n!\nPeritoneal endometriosis\nExclusively endocrine therapy has been shown to have results\ncomparable to the outcomes after surgery, at least for peritoneal\nendometriosis. Given the existing uncertainty about detecting\nthe extent of endometriotic lesions and the potential use of ex-\nclusively endocrine therapy as an alternative to surgery [15, 16],\nit is important in individual cases to weigh the extent of the po-\ntential excision against the risk of overtreatment.\nOvarian endometriosis\nAfter peritoneal endometriosis, the ovaries are the second most\ncommon site for endometriosis. But although surgery to treat\novarian endometriomas is assumed to be a routine procedure, it\ninvolves particular challenges for the surgeon.\nAs the reported rate of recurrence ranges from 9.6 –45.5 % [17,\n18], the surgeon must weigh the necessity for adequate excision\nagainst the potential iatrogenic decrease in ovarian reserve. Anal-\nysis of anti-Müllerian hormone (AMH) levels showed that sur-\ngery for ovarian endometriosis was associated with a significant\ndecrease in AMH concentrations [19 –21]. AMH levels decreased\nby 24 % after unilateral surgery and by up to 67 % after bilateral\nsurgery [22, 23].\nMeticulous dissection to expose the correct cleavage plane\n(l\n\" Fig. 3) by an experienced surgeon taking special care to pre-\nserve the ovarian hilum is recommended as the optimal surgical\ntechnique [24–26]. The benefits of excision as opposed to electro-\nsurgical ablation have been demonstrated and confirmed in an\nextensive meta-analysis [27 –29]. The analysis by Dan and Limin\n[29] compared the data of seven studies and found that, com-\npared to ablation, excision was associated with a significantly re-\nduced risk of symptom recurrence (RR 0.29; 95 % CI: 0.15 –0.55;\np < 0.001) and a significantly reduced rate of recurrence (RR\n0.50; 95 % CI: 0.26–0.97; p = 0.04). Recurrence rates after excision\nwere also lower compared to laser vaporisation (RR 0.33; 95 % CI:\n0.12–0.88; p = 0.03). The achieved pregnancy rates after excision\nwere also significantly better compared to electrosurgical coagu-\nlation (RR: 2.64; 95 % CI: 1.49 –4.69; p < 0.001), but not compared\nto laser vaporisation (RR: 0.92; 95 % CI: 0.30 –2.80; p = 0.89). Data\non ovarian reserve was not analysed in this meta-analysis.\nOne study postulated that impairment of ovarian function could\nbe prevented by replacing bipolar coagulation with a haemostatic\nsuture [30], but this could not be confirmed in a prospective ran-\ndomised study; instead, it was found that AMH levels decreased,\nirrespective of the technique used [31].\nThe indication for surgery requires the potential benefits of bet-\nter pain management or better access to growing follicles in IVF,\nwhich would otherwise be obscured by endometrioma, to be\nweighed against a potentially significant impairment of ovarian\nreserve [32]. It is, of course, obvious that unclear ovarian masses\nneed to be identified histologically.\nDeep infiltrating endometriosis\nThe indication for surgery for deep infiltrating endometriosis is\nusually severe pain. Complete excision may require expanding\nthe procedure to include the vagina, intestines and ureters, but\ncomplete surgery has been shown to control symptoms and re-\nduce the rate of recurrence [7, 33–35]. The majority of procedures\ncan be carried successfully using laparoscopy; the rate of conver-\nsion to laparotomy is between 1.6 and 12 % [36 –38].\nIn addition to the demanding surgical technique which requires a\nhigh degree of specialisation, other major challenges are plan-\nning and correctly determining the extent of surgery. A risk-ben-\nefit analysis weighing the benefits of pathological and anatomical\nradicality against benefits and risks of more limited procedures\nmay be necessary. The question whether limited surgery could\npotentially not increase the rate of recurrence if the remnants left\nin situ in the intestine or vagina were asymptomatic preopera-\ntively is still discussed controversially [39], but can obviously\nnot always be estimated properly.\nFor specialised centres, the reported complication rates in the\nimmediate postoperative period are 2 –4 % [8, 9], the overall rate\nof serious complications is 7 –9 % [36–38, 44] and the rate of re-\ncurrence is 8 –13 % [38, 40–42]. In view of the complexity of the\nintervention, these rates appear to be within “acceptable” ranges.\nHowever, the potentially serious nature of early and late compli-\ncations and unwanted side-effects and outcomes may make the\nfinal result after surgery almost insupportable for individual pa-\ntients.\nFactors which need to be taken into account range from the gen-\neral risks which depend on the extent of the intervention to the\nspecific risks of surgery for endometriosis.\nGeneral risks can be irrespective of the diagnosis of endometrio-\nsis. For example, observational studies have reported a causal as-\nsociation between lengthy surgical procedures with the patient\nin the lithotomy position and serious lower limb compartment\nsyndrome [43, 44].\nColorectal surgery is a common endometriosis-specific risk. In\none case series, revision surgery after segmental resection was\nrequired in the first week after primary surgery in 4.1 % of cases\n[9]. Anastomotic insufficiency was reported in 0.7 –3 % of cases\n[36, 45].\nA protective ileostomy is done in 3 –14.5 % of cases. One study re-\nported the regular creation of a protective ileostomy during sur-\ngery in 95.2 % of cases [36, 38, 45, 46]. From a surgical point of\nview, this is not a complication but a necessary measure to avoid\ncomplications, but for a young woman with endometriosis this\nfrequently constitutes a barrier against intervention when taking\nthe decision to undergo surgery.\nAnother study reported late functional impairments which took\nthe form of either severe constipation or pathologically increased\nfrequency of daily stools in 52 % of patients who had segmental\nFig. 3 Meticulous dissection to expose the cleavage plane in right-sided\novarian endometriosis.\n920\nRimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923\nGebFra Science\n\n\nresection, and in 19 % of patients who had nodule resection [47].\nWhen surgery is adapted intraoperatively, the goal is to reduce\nthe radicality of the procedure as far as possible. Less radical sur-\ngical techniques include the so-called shaving technique to pre-\nserve the intestinal wall [42] and discoid resection instead of seg-\nmental resection to preserve bowel continuity [48, 49]. Unfortu-\nnately there are no comparative prospective studies for these\ntechniques. But adequate complete resection of the endometri-\notic nodule must be ensured, as otherwise there is an increased\nrisk of recurrence. In the study of Brouwer and Woods, the recur-\nrence rates of 2.19 % after segmental rectal resection and 5.17 %\nafter full-thickness excision of the anterior rectal wall rose signif-\nicantly to 22.2 % after what was probably incomplete dissection\noff the rectal wall [45].\nAnother study reported severe urological complications such as\nhydronephrosis in 4.8 %, urinary fistulas in 3 % and bladder void-\ning dysfunction in 28.9 % after colorectal resection with partial\ncolpectomy [50].\nVoiding dysfunction rates after resection are reported to be 15 –\n30 %, but voiding dysfunction is likely to affect the majority of all\npatients in a mild and transient form after complex resection of\ndeep infiltrating endometriosis and can even result in a perma-\nnent need for self-catheterisation. The cause of voiding dysfunc-\ntion is autonomic nerve damage, particularly iatrogenic injury to\nthe inferior hypogastric plexus at the proximal portion of the\nuterosacral ligament during resection of the uterosacral liga-\nments, of the parametrium, the deep rectum and the vaginal cuff\n[51–53] (l\n\" Fig. 4 a und b). Postoperative rates of urinary dysfunc-\ntion could be reduced if nerve structures are identified and\nspared intraoperatively [54, 55].\nIf hydronephrosis is present, ureteral involvement must always\nbe considered; however, ureteral involvement may be silent and\ncompletely asymptomatic [56]. In one study of patients with ret-\nrocervical endometriosis in the vicinity of the uterosacral liga-\nments, ureteral involvement was present in 17.9 % of cases with\nnodules ≥ 3 cm compared to 1.6 % of cases with nodules < 3 cm\n[57]. Ureterolysis was reported to be successful in the majority\nof cases (53.8–73.3 %) [56, 58, 59], but complication rates were be-\ntween 23 and 31.4 % [58, 59].\nSpecial Situations: Adolescence and Recurrence\n!\nBoth situations, although completely dissimilar, confront the sur-\ngeon with the same necessity to weigh the benefits against the\nrisks of an invasive or repeat invasive procedure.\nIn adolescence, qualms about the invasiveness of laparoscopy\nmay result in a delay in diagnosis of several years [60]. Further\nsystematic reviews will be necessary to confirm the data of one\nstudy which reported the prevalence of endometriosis to be 70 –\n75 % in girls with therapy-resistant, chronic, pelvic pain and dys-\nmenorrhea [61]. The limited data available on treatment out-\ncomes is controversial. One study came to the conclusion, based\non the data for re-interventions, that early laparoscopic excision\nhad the potential to eradicate disease [62]. Another study of 57\nwomen ≤ 21 years who underwent laparoscopy for endometrio-\nsis reported an unusually high rate of 56 % of patients suspicious\nfor recurrence and a constant increase in recurrence rates over\nthe 5-year follow-up period and concluded, based on these data,\nthat early surgical intervention was associated with a particularly\nhigh risk of recurrence [63].\nCaution is advised with regard to re-operations of patients with\nsymptomatic recurrence, particularly patients who have had re-\npetitive surgical interventions for endometriosis. The cumulative\nprobability for further surgical interventions was found to be at\nleast 15 –20 %, although the authors of the study surmised that\npublication bias meant that these data were probably an under-\nestimate [64]. Re-operation for recurrence and pelvic pain was as\nefficacious as primary surgery and had comparable limitations\n[65]; however, with regard to the desire for conception, preg-\nnancy rates after re-operation were only half of those achieved\nafter primary operation.\nConclusion\n!\nThe aim of this overview was to discuss controversial aspects and\nchallenges in the surgical treatment of endometriosis. This dis-\ncussion has made it clear that significant challenges still remain\nwith regard to preoperative diagnosis and decision-making, the\nprovision of information to patients and surgical techniques to\ntreat endometriosis.\nConflict of Interest\n!\nNone.\nFig. 4 a and ba Endometriotic nodules with infiltration of the vaginal\ncuff; the fibres of the right inferior hypogastric plexus are immediately lat-\neral to the nodules. b Resection of vaginal endometriosis preserving the\ninferior hypogastric plexus.\n921\nRimbach S et al. 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