Excision Therapy

Why do you feel conservative, aggressive excision therapy is best for treating deep endometriosis?

When a patient has deeply invasive endometriosis of the posterior cul de sac or rectovaginal septum, or encapsulated ovaries fixed to the pelvic sidewall by adhesions and possibly retroperitoneal, a tension arises in the young patient who definitely has her childbearing years in front of her. How do we best treat this woman’s pain while preserving as best we can her right to make decisions about future pregnancies?

Many gynecologists are critical of the meticulous excision of endometriosis deep into the rectovaginal septum and pelvic sidewall because they think it will result in a flood of pelvic adhesions. If adhesions do occur, they again believe the relative risk of infertility will increase. Fearing that endometriosis will return no matter what they do, they aren’t likely to support a meticulous pelvic dissection as the best form of treatment. Their approach would be to leave the deep disease untreated and prescribe suppressive medication. They would encourage pregnancy as soon as it becomes feasible for the individuals involved.

I favor excision of deep endometriosis even in the young patient for the following reasons:

Limited surgery followed by medical suppression means the patient undergoes both surgery and the medication treatment. Side effects of the medication are considerable, sometimes incapacitating, and frequently quite expensive. Additionally the patient must still deal with any residual symptoms of the endometriosis left behind. Many times the "limited surgery" results in skimming the top off the area of deep disease, leaving behind the remainder. This allows subsequent adhesion formation to bury deep disease. Deep disease covered by new adhesions actually increases the pain, leaving a very dissatisfied patient.

In contrast, with lapex (laparoscopic excision), all endometriosis is removed. Any adhesions that may form will do so immediately post op, because no disease has been left behind to create new ones on an ongoing basis. Our follow-up surveys dating back to 1991 for hundreds of women demonstrate a recurrence rate of only 10-15%. More than 85 of every 100 women will have no more endometriosis. Of the remaining patients, those who do have endometriosis generally have one or two small foci that were not removed at surgery. This can be by accident or design (as in the case of a woman with very limited tubal endometriosis, where it is felt that deep excision could lead to scarring contraindicated in a woman trying to conceive. Such cases are very infrequent).

Adhesions that result from conservative aggressive lapex actually vary greatly from patient to patient. In my experience patients have as much risk of adhesion formation from the progression of disease that persists or that was untreated as from excisional surgery. If the ultimate risk of adhesions is the same in both cases, why not relieve the pain by getting rid of the disease?

The sooner in a woman’s life the disease can be eradicated, the better her long-term outlook becomes. Drug therapy that can destroy endometriosis has yet to be discovered. The best such drugs can do is (sometimes) suppress endometriosis. So a woman who uses such medications keeps herself at risk that the effects of her endometriosis will worsen.

I believe that the best treatment for young women in this situation is for a surgeon with a great deal of experience with endometriosis to perform aggressive conservative surgery. The surgeon should use the most appropriate surgical techniques to minimize adhesion formation (see Adhesions). As for possible future pregnancies, I always feel that a woman who gets herself healthy first will be in a much better position to be the best possible mother to her child. And, although it is true that some cases of infertility can be traced to endometriosis, most women with endometriosis who want to have babies, have babies. The automatic assumption that a woman with endometriosis will have difficulty conceiving is simply not true. Each case should be evaluated individually, and each woman’s goals, feelings, and attitudes carefully considered.

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