SURGICAL TREATMENT OF ENDOMETRIOSIS

SURGICAL TREATMENT OF ENDOMETRIOSIS : 

SURGICAL TREATMENT OF ENDOMETRIOSIS By Farnaz Mohammadzadeh Obstetrician and Gynecologist Dr. farnaz mohammadzadeh

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Therapeutic planning depends on: Age Desire for fertility or pain relief Duration and intensity of symptoms Extent of disease Previous treatments Dr. farnaz mohammadzadeh

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Preservation of reproductive function is desirable The least invasive and least expensive approach The objectives are: -To restore normal anatomic relationships -To excise or destroy all visible disease -To prevent or delay recurrence Dr. farnaz mohammadzadeh

laparoscopy : 

Better visualization Less tissue trauma Smaller incision Speeder post operative recovery Less post operative adhesions Less cost Results are equivalent to or better than laparotomy Dr. farnaz mohammadzadeh laparoscopy

laparotomy : 

For advanced_stages(dense pelvic adhesions, endometriomas greater than 5cm, involvement of ureter,bowel and uterine vessels) For those in whom fertility conservation is not necessary Dr. farnaz mohammadzadeh laparotomy

Preoperative hormonal treatment : 

3 months of medical treatment to reduce vascularization and nodular size in severe endometriosis Failed to show a significant difference in ease of surgery. The only exception is deep rectovaginal endometriosis that preoperative medical treatment can decrease recurrence and symptoms. Dr. farnaz mohammadzadeh Preoperative hormonal treatment

Peritoneal endometriosis : 

Sharp dissection (tissue margin of at least 2-4mm) Unipolar or bipolar electrosurgical instruments Laser (co2) for lesions less than 5mm under a constant stream of irrigation) Dr. farnaz mohammadzadeh Peritoneal endometriosis

Adhesions : 

Excision is preferable to simple lysis because adhesions will frequently contain disease. To improve operative outcomes use of magnifications , minimum tissue trauma and exposed suture and meticulous homeostasis is necessary. Dr. farnaz mohammadzadeh Adhesions

Ovarian endometriosis : 

Superficial ovarian lesions can be vaporized Ovarian endometrioma<3cm can be aspirated, irrigated, and inspected with ovarian cystoscopy for intracystic lesions.Their interior wall can be vaporized. Ovarian endometrioma>3cm should be aspirated following incision and removal of cyst wall from the ovarian cortex to prevent recurrence. Based on current evidence ovarian cystectomy appears to be the method of choice. Dr. farnaz mohammadzadeh Ovarian endometriosis

Deep rectovaginal and rectosigmoid endometriosis : 

Disease includes smooth muscle as well as endometrial glands. preoperative investigations: _sonography _IVP _colon contrast radiography _MRI bowel prep Dr. farnaz mohammadzadeh Deep rectovaginal and rectosigmoid endometriosis

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Laparoscopy Laparotomy Laparoscopically asisted vaginal technique Surgery involves thorough dissection and exposure of the anterior rectum, the posterior vagina and nodular disease . 6% bowel wall resection 14% posterior vaginal fornix resection ureter stent multidisciplinary approach Dr. farnaz mohammadzadeh

Presacral neurectomy(PSN) : 

Interrupting the sympathetic innervation of uterus at the level of the superior hypogastric plexus Greater pain relief after 12months(86% versus 57%) Only in those with midline pain Dr. farnaz mohammadzadeh Presacral neurectomy(PSN)

Laparoscopic uterosacral nerve ablation(LUNA) : 

Destruction of the midportion of the uterosacral ligaments. Side effects:bowel or bladder dysfunction Candidates for PSN and LUNA must be very carefully selected. Dr. farnaz mohammadzadeh Laparoscopic uterosacral nerve ablation(LUNA)

Radical surgical treatment : 

When medical and conservative surgical treatment fails. TAH+BSO+all visible endometriotic tissue Laparoscopically , abdominally , vaginally The choice of procedure will depend on equipment availability,operator experience and extent of disease. In highly selected women having no significant ovarian disease hysterectomy alone can be considered(6 fold recurrence) Dr. farnaz mohammadzadeh Radical surgical treatment

Postoperative medical treatment : 

When the primary objective of surgical treatment is relief from pain and pregnancy is not an immediate goal,postoperative medical treatment may have value,particularly with extensive disease or residual disease. Dr. farnaz mohammadzadeh Postoperative medical treatment

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After conservative treatment in infertile women, a choice between expectant management and active treatment must consider : - age - the surgical results - the influence and severity of any other infertility factor Dr. farnaz mohammadzadeh

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In young women with limited desease and unexplained infertility of short duration: expectant but not longer than 6-9month In longer duration of infertility and more advanced endometriosis and in older women: a more aggressive aproach involving immediate further empiric treatment with combination of clomiphene or exogenous gonadotropins and IUI or even IVF is justified Dr. farnaz mohammadzadeh

Postoperative HRT : 

After radical surgery in most women with negligible risk of inducting growth of residual disease , it can begin immediately. In those with extensive disease an interval of 3month without hormone treatment or one progestin _only treatment is prudent. MPA 20mg/daily have value for both: Direct suppressive effect on any residual foci Alleviation of vasomotor symptoms With HRT there is increased risk of breast cancer and heart disease. Dr. farnaz mohammadzadeh Postoperative HRT

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Low dose combined is recommended over estrogen alone even though the uterus is absent because of reports of adenocarcinoma arising from endometriosis in women treated with unopposed estrogen Dr. farnaz mohammadzadeh

Results of surgical treatment on pain : 

Psychological factors:personality, depression, marital and sexual problems Placebo response(in diagnostic laparoscopy) Endometriosis stage:positive correlation between endometriosis stage and endometriosis_related dysmenorrhea or chronic pelvic pain Cystectomy provides longer term relief than drainage PSN and LUNA can be effective for relieving dysmenorrhea and midline pain but little benefit for dyspareunia and intermenstrual pain Dr. farnaz mohammadzadeh Results of surgical treatment on pain

Results of surgical treatment on subfertility : 

Minimal to mild:surgery may improve fertility Moderate to severe:there is not enough study to compare , but the results are better than no treatment.They are candidates for fertility treatments. Dr. farnaz mohammadzadeh Results of surgical treatment on subfertility

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Thanks for your attention