Endoscopic management of endometriosis.

Randomized clinical trials in the effectiveness of laparoscopic surgery in the management of endometriosis associated with chronic pelvic pain show a 66% to 80% response rate. There is a 20% to 30% ''placebo'' response rate. The value of surgery for infertile patients with minimal and mild disease is still debated but is most likely small. In advanced disease, surgery clearly improves outcome, although the surgery is more challenging. After an initial unsuccessful surgery for restoration of fertility in patients with advanced endometriosis, in vitro fertilization rather than repeat surgery is more effective. Laparoscopic treatment of endometriomas should be performed by excisional surgery. Drainage and/or medical therapy is associated with a very high recurrence rate. The main concern with excision of endometriomas is the potential to decrease ovarian reserve. Most experts would agree that if there is an endometrioma of 4 cm or greater that a laparoscopic excision be performed before an anticipated in vitro fertilization cycle to decrease the potential risk of infection and improve access to follicle. Surgery for pelvic extragenital disease is challenging. Excision of rectal endometriosis may require disc excision of the nodular lesion or segmental resection. Morbidity of a laparoscopic procedure is similar to laparotomy. Relief of symptoms after laparoscopic bowel surgery is excellent but there are potential complications such as rectovaginal fistula and pelvic abscess. Endo-metriosis of the bladder or ureter typically only involves the overlying peritoneum and can be easily excised by laparoscopy. Excision of deeper lesions of the bladder and ureter require resection. This can be accomplished laparoscopically but requires experience with laparoscopic suturing.