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Endometriosis: Surgical management of pelvic pain

Endometriosis: Surgical management of pelvic pain
Literature review current through: Jan 2024.
This topic last updated: Jul 25, 2023.

INTRODUCTION — Endometriosis is a chronic gynecologic condition in which endometrial glands and stroma exist outside the uterus. These implants are predominately found in the pelvis but may be present anywhere in the body. This ectopic endometrium can cause scarring, infertility, and pain. The surgical management of pelvic pain due to endometriosis is reviewed here. Related topics are discussed separately, including:

(See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact".)

(See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Evaluation'.)

(See "Endometriosis in adolescents: Diagnosis and treatment".)

(See "Endometriosis: Treatment of pelvic pain".)

(See "Endometriosis of the bladder and ureter".)

(See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)

GENERAL PRINCIPLES — The American Society for Reproductive Medicine Practice Committee states that "endometriosis should be viewed as a chronic disease that requires a lifelong management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures" [1]. Therefore, treatment decisions are individualized and consider clinical presentation (eg, pain, infertility, mass), symptom severity, disease extent and location, reproductive desires, patient age, medication side effects, surgical complication rates, and cost. Therapies for endometriosis-related pelvic pain include analgesics, hormonal treatments, and surgical intervention, and a combined approach is often used. (See "Endometriosis: Treatment of pelvic pain".)

Prior to any treatment, all women should have a thorough history and examination, and other causes of pelvic pain should be excluded. (See "Chronic pelvic pain in adult females: Evaluation".)

Surgical intervention provides a histologic diagnosis, allows assessment of pelvic cysts or masses with features concerning for malignancy, and reduces pain by destroying the endometriotic implants [1,2]. We consider surgery in women with the following:

Persistent pain despite medical therapy

Contraindications to or refusal of medical therapy

Need for a tissue diagnosis of endometriosis

Exclusion of malignancy in an adnexal mass (see "Endometriosis: Management of ovarian endometriomas")

Obstruction of the bowel or urinary tract (see "Endometriosis of the bladder and ureter" and "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease")

Although extent of disease correlates poorly with severity of symptoms, women with more extensive disease may have improved pain relief from surgical treatment than women with less extensive disease [3-5]. A trial of 63 women reported greater symptomatic improvement six months postoperatively in women with stage II or III disease compared with stage I disease (75 versus 46 percent) [6,7].

Disadvantages of surgery include risk of injury (especially the bowel and bladder), possible reduction of ovarian reserve (eg, after ovarian cyst excision), and adhesion formation, in addition to standard surgical risks. Information on the impact of endometrioma surgery on ovarian reserve is presented separately. (See "Endometriosis: Management of ovarian endometriomas", section on 'Consider importance of ovarian reserve'.)

We typically avoid surgery in women with the following:

Women with incompletely evaluated pelvic pain (see "Chronic pelvic pain in adult females: Evaluation")

Women with persistent pelvic pain after repeated surgeries (see 'Repeat surgery' below)

Women nearing menopause unless there is a suspicion of malignancy

Endometriosis symptoms typically resolve with menopause. Women who are close to menopause may prefer to tolerate suboptimally controlled symptoms in order to avoid surgery. Menopause can be anticipated in a woman who is approaching the average age of menopause (51 years) or has symptoms of the menopausal transition. Whether or not to proceed with surgery in these women depends upon each woman's assessment of her quality of life compared with the benefits of avoiding surgery. (See "Clinical manifestations and diagnosis of menopause".)

SURGICAL PLANNING — Preoperative planning involves assessing the patient's desired surgical outcome and counseling the patient regarding the extent and approach of the planned surgery.

Conservative versus definitive surgery — Conservative surgery involves excision or ablation of endometriotic lesions with the intent of preserving the uterus and as much ovarian tissue as possible [1]. Conservative surgery is the first-line option for most women planning surgical treatment of endometriosis because it preserves fertility and hormone production, is less invasive and morbid than definitive surgery, and has documented short-term efficacy. In general, excision is preferred over ablation [2].

A 2014 systematic review and meta-analysis of 10 trials on laparoscopic surgery for endometriosis reported that conservative laparoscopic surgery reduced overall pain (73 versus 21 percent) and increased live birth or ongoing pregnancy rates (30 versus 18 percent) compared with diagnostic laparoscopy [8]. Pain reduction was similar for laparoscopic excision compared with laparoscopic ablation, but the data were limited. A survey study of 154 patients who underwent surgery for endometriosis or chronic pelvic pain reported that 90 percent agreed or strongly agreed that choosing excisional surgery was the right decision, and 87 percent stated they would choose surgery again [9].

The disadvantage of conservative surgery is that the rate of recurrent symptoms is higher compared with definitive surgery (hysterectomy with or without oophorectomy), particularly in younger individuals [10]. The rate of reoperation appears to increase over time for conservative surgery, whereas it remains relatively stable for definitive surgery [10-12].

In a retrospective cohort study of 240 women who underwent either laparoscopic resection or hysterectomy for endometriosis-related symptoms, over seven years of follow-up, repeat surgery was more common in those who underwent resection (58 versus 19 percent, respectively) [10]. Both surgical groups retained their ovaries. This study also reported an inverse age-related recurrence rate; surgery on younger women was associated with a higher probability of recurrence over time (seven-year recurrence risk 72 percent for individuals aged 19 to 29 years, 56 percent for those aged 30 to 39 years, and 24 percent for those aged 40 years or greater). The lowest reoperation rate, 8 percent, was in the subgroup of women who underwent hysterectomy and bilateral oophorectomy.

In a larger retrospective study of over 50,000 patients who underwent initial laparoscopic resection or hysterectomy, the reoperation rates at eight years of follow-up were 35 and 5 percent, respectively [13,14]. A recent population-based cohort study of over 80,000 women with a median follow-up of 10 years showed that few endometriosis patients that undergo hysterectomy required repeat surgery, but one in four who undergo minor and one in five who undergo major conservative surgery require additional endometriosis surgery [14].

Definitive surgery includes hysterectomy, with or without oophorectomy. Definitive surgery is offered to women with debilitating symptoms that are likely from endometriosis, have completed childbearing, and have failed other treatment options [1]. The main disadvantages of definitive surgery are the surgical risks, loss of fertility, and symptoms of surgical menopause.

Hysterectomy — We reserve hysterectomy for women with persistent bothersome symptoms of endometriosis who do not plan future childbearing and who have failed both medical therapy and at least one conservative treatment procedure. Definitive surgery is also reasonable for women who have additional indications for hysterectomy (eg, symptomatic fibroids or prolapse). Hysterectomy alone is an effective treatment for pain symptoms of endometriosis, with a reoperation rate of 19 percent in one study, compared with a 58 percent reoperation rate for women undergoing conservative surgery (table 1) [10]. In this study, all visible endometriosis was ablated or excised at the time of hysterectomy with conservation of ovaries. Furthermore, we recommend total hysterectomy and not a subtotal (supracervical hysterectomy [2]).

The main benefit of hysterectomy is a lower long-term reoperation rate for endometriosis-related symptoms compared with conservative surgery, as discussed above.

Disadvantages of hysterectomy include loss of reproductive ability, higher surgical complication rates, negative impact on body image, and earlier loss of ovarian function. In general, hysterectomy is associated with higher surgical complication rates compared with laparoscopic surgery. Prospective studies of over 37,000 hysterectomies reported an overall complication rate of 3.5 percent [15,16] compared with a 0.2 percent laparoscopic complication rate as reported by a retrospective series of 1894 laparoscopic procedures [17]. In addition, some women who undergo hysterectomy experience regret for loss of fertility [18]. As an example, a study of 311 women younger than 45 years of age who had a hysterectomy for various indications reported that up to 43 percent felt regret about the loss of fertility despite a surgical satisfaction rate of greater than 90 percent [19]. (See "Hysterectomy (benign indications): Patient-important issues and surgical complications".)

We counsel women that hysterectomy without bilateral salpingo-oophorectomy and conservative surgery are not equivalent in terms of preservation of hormonal function. Women who undergo hysterectomy with conservation of ovaries are likely to experience menopause one to four years earlier than women who retain their uterus [20-26]. Hysterectomy alone (ie, without bilateral salpingo-oophorectomy) is performed for women who desire pain control and preservation of ovarian hormonal function.

Role of oophorectomy — Women who benefit from oophorectomy include those with extensive adnexal disease and those for whom the risks of reoperation outweigh the risks of premature menopause. Oophorectomy likely increases the efficacy of definitive surgery but is also accompanied by the quality-of-life issues and potential adverse health effects of premature menopause. There are no data that establish an age-based cut-off for oophorectomy. In our practice, we counsel all women undergoing definitive surgery about the risks and benefits of oophorectomy, and we discourage oophorectomy in women younger than 50 years unless there is extensive ovarian disease.

The rationale for ovary removal is that endometriosis is an estrogen-dependent disease. Removal of both ovaries creates a postmenopausal state and theoretically reduces pelvic pain caused by endometriosis. These women are counseled that surgical menopause will result from bilateral oophorectomy, and these symptoms must be balanced against the pain symptoms from endometriosis. Treatment for vasomotor symptoms of surgical menopause is discussed below. (See 'Hormone therapy for menopause symptoms' below.)

For treatment of pain, removal of the ovaries appears to be more effective than ovarian conservation in reducing endometriosis-related symptoms [10,27], but this finding has not been universally reported [19]. One reason for conflicting results is that the reoperation rate changes over time, with more repeat surgeries occurring over longer duration of follow-up. In the retrospective cohort study discussed above, the reoperation rates were 58 percent for women who underwent laparoscopic surgery with ovarian conservation, 19 percent for women who underwent hysterectomy with ovarian conservation, and 8 percent for women who underwent hysterectomy and bilateral salpingo-oophorectomy (table 1) [10]. For women who had a hysterectomy and underwent reoperation, the repeat surgeries consisted of removal of ovaries or ovarian remnants and excision/ablation of endometriotic lesions.

Disadvantages of bilateral oophorectomy include premature menopause, menopausal symptoms, and the potential for long-term deleterious health effects. Early menopause, defined as menopause in women age 44 or younger, increases the risks of overall mortality, cardiovascular disease, neurologic disease, osteoporosis, and psychiatric illness [28-32]. It is uncertain whether these effects are ameliorated by hormone therapy (see 'Hormone therapy for menopause symptoms' below). The effects of oophorectomy are discussed in detail separately. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy".)

Treatment with oophorectomy alone without hysterectomy has not been well studied and is not common practice [10]. Since oophorectomy results in the loss of both hormonal and reproductive function, there is little advantage to retaining the uterus unless the patient desires to become pregnant by an assisted reproductive technology procedure, such as using her own frozen oocytes, embryos, or donor oocytes. It is unclear whether hysterectomy affects future risk of pelvic organ prolapse when performed for the indication of endometriosis-related pain. (See "Prophylactic vaginal apex suspension at the time of hysterectomy", section on 'Impact of hysterectomy on future prolapse risk'.)

Even for women who have undergone an oophorectomy, there may be retained ovarian tissue that contributes to recurrent pelvic pain. When multiple conservative procedures have been performed over time, it may be difficult to successfully perform a bilateral salpingo-oophorectomy because some of the ovarian tissue has become loculated in the retroperitoneum and is difficult to find and remove. (See "Oophorectomy and ovarian cystectomy", section on 'Ovarian remnant syndrome'.)

Laparoscopy versus laparotomy — Laparoscopic surgery is generally preferred to laparotomy because it is associated with improved surgical visualization (from lens magnification), less pain, shorter hospital stay, quicker recovery, and better cosmetic outcome [2,33,34]. Laparoscopy is performed for the great majority of procedures for treatment of endometriosis, regardless of the severity of disease. The choice of surgical approach for hysterectomy is made based upon the same factors as used for other gynecologic indications. (See "Hysterectomy (benign indications): Selection of surgical route", section on 'Route of hysterectomy for benign disease'.)

A multicenter trial (73 patients) comparing robot-assisted laparoscopy with conventional laparoscopy reported similar operative times, perioperative complications, and quality of life between the two groups [35]. Somewhat older studies have reported that robotic surgery generally takes longer, which could reflect disparate groups, larger study sample sizes, or decreased familiarity with the technology [36,37]. It is hypothesized that in patients with lesions in complex anatomic sites (eg, retrocervical lesions), a robot-assisted approach may provide improved instrument articulation compared with conventional laparoscopy, but no data are available.

Laparotomy may be necessary when dealing with extensive adhesions or invasive endometriosis located near structures such as the uterine arteries, ureter, bladder, and bowel.

PREOPERATIVE EVALUATION — The preoperative evaluation includes studies pertinent to the patient's symptoms (eg, pelvic ultrasound for pelvic pain) in addition to routine preoperative evaluation for gynecologic surgery.

(See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Evaluation'.)

(See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

Preoperative findings suggestive of deep endometriosis or extrapelvic disease can aid surgical planning. DIE refers to lesions that penetrate to a depth of 5 mm or more. These lesions are frequently multifocal and may involve the uterosacral ligaments, retrocervical space, bowel, ureteral, and/or bladder [38]. A nodule infiltrating the rectosigmoid colon can appear as a single "moose antler" on pelvic ultrasound or the so-called "moose antler sign" [39]. Complete resection requires appropriate surgical expertise that often includes a multidisciplinary surgical team (general surgeon, urologist).

If DIE is suspected based on symptomatology (eg, dysuria, dyschezia, hematochezia) and/or physical examination (eg, uterosacral ligament tenderness with dense nodules, nonmobile uterus), the preoperative evaluation includes testing targeted to the specific symptom. Examples include cystoscopy for evaluation or urinary symptoms or colonoscopy for evaluation of hematochezia. Extensive pelvic adhesions are difficult to diagnose with imaging, although the "sliding sign" at time of imaging may be utilized to assess for deep endometriosis and/or adhesive disease [40,41]. Additionally, magnetic resonance imaging or transvaginal sonography may suggest an obliterated pelvic cul-de-sac [42]. Evaluation of the gastrointestinal and urinary tracts is discussed separately. (See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease" and "Endometriosis of the bladder and ureter".)

Similarly, if extrapelvic disease is suspected (eg, umbilical, inguinal, diaphragmatic lesions), appropriate preoperative evaluation should be performed. (See 'Extrapelvic sites' below.)

PREOPERATIVE PREPARATION

Informed consent and preoperative counseling — The preoperative informed consent discussion includes a review of the risks and benefits of the planned procedure compared with the risks and benefits of alternative treatment options. Patients are counseled that there is a high rate of success in the short term, but risk of symptom recurrence increases over time, particularly for women undergoing conservative surgery [10]. We discuss long-term (greater than six months) use of postoperative hormonal treatment in patients not trying to conceive. This provides secondary prevention of endometriosis-associated dysmenorrhea but does not clearly prevent nonmenstrual pain or dyspareunia [2,43]. (See "Informed procedural consent", section on 'Informed decision-making'.)

Preoperative medical suppressive therapy — We recommend not giving preoperative medical suppression for the indication of improved surgical outcome, similar to societies' position statements [1,2,44]. There is no evidence that preoperative hormonal intervention decreases the extent of surgical dissection required to remove implants, prolongs the duration of pain relief, increases future pregnancy rates, or decreases recurrence rates [43].

Thromboprophylaxis — Use of mechanical or pharmacologic prophylaxis depends upon the procedure and patient risk factors. This is discussed in detail separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Pharmacologic dosing'.)

Antibiotic prophylaxis — Operative laparoscopy is typically a clean procedure, and antibiotic prophylaxis is generally not indicated unless vaginal or intestinal surgery is likely (table 2) [45].

Bowel preparation — In our practice, we give prophylactic antibiotics if there is suspicion of adhesive bowel disease because of the increased risk of bowel injury (table 2) [45]. There is no evidence that oral antibiotics or mechanical bowel preparation further decreases the risk of infection beyond that provided by parenteral antibiotics [46]. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Bowel preparation'.)

SURGICAL PROCEDURES — Surgical treatment involves both diagnosing the location and extent of endometrial lesions and treating the lesions with some form of destructive therapy.

Exploration and diagnosis — The initial step is exploration of the pelvis and abdomen, identification of endometriotic lesions, and determination of lesion locations and characteristics (eg, superficial versus deep). Exploration is also necessary at the start of subsequent procedures, since an understanding of the location and characteristics of lesions is critical to the extirpation of the disease. Laparoscopy is the preferred surgical approach, when possible. Once all lesions have been identified, then disease classification and surgical planning for treatment can begin.

We use the following approach during surgical assessment of endometriosis:

Thoroughly inspect the pelvis for endometriotic lesions. The reproductive organs and ligaments (uterosacral ligaments, round ligaments), peritoneal surfaces (anterior and posterior pelvic cul-de-sac, pelvic sidewalls), and sigmoid colon are evaluated for lesions. The anatomic distribution of endometriosis is discussed in detail separately. (See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact", section on 'Anatomy and staging'.)

Perform a bimanual pelvic examination while observing the posterior cul-de-sac via the laparoscope to discern the location of posterior cul-de-sac lesions (movie 1).

Evaluate the appendix, as 2 to 4 percent of women with endometriosis have appendiceal endometriosis [47].

Explore all extrapelvic sites that may be impacted based on the patient's history. As an example, if the patient has symptoms of urinary tract involvement, the retroperitoneum is dissected to examine the ureters. Similarly, in a patient with upper abdominal pain or gastrointestinal symptoms that appear to be associated with endometriosis, the entire bowel and/or diaphragm is examined. (See "Endometriosis of the bladder and ureter" and "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)

Use a dye to stain the peritoneum and assist in identifying lesions [48-51]. Autofluorescence [48] and photosensitization of lesions with hematoporphyrin derivatives [49] have also been reported to improve detection of subtle lesions. In a systematic review of nine studies, 5-aminolevulinic acid induced fluorescence, autofluorescence, and narrow-band imaging all had higher detection rates for peritoneal endometriosis compared with conventional white light laparoscopy [52,53]. It is not known if the added time and expense of using these technologies will improve women's pain symptoms.

In our practice, we use methylene blue in a 1:200 dilution with sterile saline. We inject this through a laparoscopic aspiration needle. Excess dye is rinsed away and the pelvis is inspected for any blue dye. Uptake of dye often helps to detect subtle endometriosis implants not otherwise apparent with conventional laparoscopic light.

Look for deep infiltrating endometriosis. Assessment of peritoneal mobility can help distinguish deep lesions from superficial ones. Deep lesions will prevent the peritoneum from sliding, as it is tacked down to the underlying structures.

Endometriotic implants can have many appearances (movie 2). The gross and microscopic appearance of endometriosis is discussed in detail separately. (See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact", section on 'Histology and lesion phenotypes'.)

Surgical exploration also includes identifying lesions that may be confused with endometriosis, including endosalpingiosis, mesothelial hyperplasia, hemosiderin deposition, hemangiomas, adrenal rests, inflammatory changes, splenosis, and reactions to oil-based radiographic dyes [54]. Splenic implants have anatomic distribution and imaging characteristics similar to endometriosis, but splenic implants are generally asymptomatic [55-57]. Splenosis is excluded by biopsy of suspicious lesions. (See "Splenomegaly and other splenic disorders in adults", section on 'Splenosis'.)

Ideally, laparoscopic findings should be photographed or recorded on video to facilitate communication with other doctors and help patients understand their disease and its implications. We find that a visual record better improves communication of disease extent and severity than a written description of disease stage alone. However, images along do not suffice and it is important to document in the medical record the type, location, and extent of all lesions and adhesions [58].

Classification of extent of disease — The information gained at the time of surgical exploration is then used to classify the severity of the disease. There are at least 22 endometriosis classification systems [59,60]; of these only the Endometriosis Fertility Index (EFI) has a correlation with patient outcomes.

The EFI can be helpful in counseling patients on how successful surgery may be for restoring fertility. As examples, patients with a low EFI score often proceed to directly to IVF while those with a high score can attempt pregnancy without IVF for six to nine months [61].

The revised American Society for Reproductive Medicine classification system describes both the quantity and severity of disease (form 1 and figure 1) [62]. Although the classification system has a poor correlation with pregnancy outcome or pain [63] but can be useful at the time of surgical re-exploration.

In our practice, we record the clinical score to compare disease severity between the initial and subsequent surgeries and to plan ahead in the event of a repeat operative procedure. As an example, if extensive adhesive disease was noted previously, then future surgical planning would include having a bowel surgeon available for intraoperative consultation.

Ablation versus excision — Surgical treatment involves the destruction of endometriotic lesions. The modalities used for treatment include:

Ablation – Eradication of lesions by laser vaporization (movie 3), electrosurgical fulguration, or ultrasonic cutting and coagulation

Excision – Removal of lesions, typically with laparoscopic scissors (movie 4)

A 2021 systematic review of three trials (n = 225 women) comparing laparoscopic excision with ablation of superficial lesions on pain outcomes one year later reported no significant difference in dysmenorrhea (mean difference [MD] -0.03, 95% CI -1.27 to 1.22), dyschezia (MD 0.46, 95% CI, -1.09 to 2.02), and dyspareunia (MD 0.10, 95% CI -2.36 to 2.56) [64]. However, one study limitation is that ablation is performed mainly for superficial lesions compared with deep ones. While the choice of modality is based on surgeon experience and preference, excision is recommended for deep lesions as ablative techniques may not penetrate sufficiently or may injure the underlying structures such as the ureter [2]. When selecting an ablative technology, the surgeon compares the depth, width, and spread of tissue damage, as they vary based on the instrument and energy utilized. Laser and electrosurgery techniques are discussed in detail separately. (See "Basic principles of medical lasers" and "Overview of electrosurgery" and "Instruments and devices used in laparoscopic surgery", section on 'Devices for hemostasis'.)

In our practice, we excise at least one lesion, and typically excise all lesions, to obtain tissue for histologic confirmation of endometriosis. It is important to appreciate the anatomy beneath the lesion and that fibrosis causes retraction, which may distort the lesion's relationship to nearby structures (eg, ureter, blood vessels). The incision is made superficially in the normal peritoneum and then the lesion is dissected off of surrounding structures. Hydrodissection can aid this separation if the disease does not have a deep component. Wide excision is useful, as nonvisualized disease has been reported up to 27 mm from the lesion in normal-appearing peritoneum [65].

We palpate the lesion with a laparoscopic grasper to determine its degree of nodularity and depth of penetration. If the decision is made to proceed with surgical treatment, we prefer excision to ablation for lesions near vital structures (eg, ureters, blood vessels) because diffusion of the ablative energy may injure these tissues as well. Excision must be done with extreme care to avoid perforation into nearby structures. Lesions adjacent to vital structures cannot always be safely treated surgically, and postoperative medical therapy is used instead. Resection of urinary tract or retrocervical endometriosis is discussed in detail separately. (See "Endometriosis of the bladder and ureter" and "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)

Radical resection of endometriosis refers to removal of all visible implants at the time of surgery. In a questionnaire study of nearly 100 women with endometriosis who underwent radical resection, the women reported significant decreases in pain scores, frequency of interrupted sexual intercourse, feelings of guilt towards the partner, being afraid of pain before/during sexual intercourse, and feelings of being a burden for the relationship at an average of 10 months postoperatively [66].

Adhesiolysis — Women with endometriosis often develop intraperitoneal adhesive disease; adhesions are reported in up to 70 percent of women (both with and without prior surgery) [67]. Red lesions are associated with more adhesions than black, white, and clear lesions [68]. Since adhesions often reform as part of the postoperative healing, and may reform in a way that exacerbates pain or infertility, surgical resection of adhesions is not always effective at reducing pain.

In our practice, we perform adhesiolysis selectively. We resect all adhesions that may compromise fertility or that correspond to the location of the patient's pain. We believe that comprehensive adhesiolysis is unwarranted because of the risk of injury to underlying critical structures (eg, blood vessels, nerves, or ureters) combined with the lack of consistent benefit.

Some women develop extensive pelvic adhesions that limit the mobility and visualization of the pelvic organs. This finding cannot always be anticipated prior to surgery and may limit the ability to adequately ablate or excise disease; more extensive surgery may be required. The term previously used for this was "frozen pelvis." In current practice, this is described as deep infiltrating endometriosis (see 'Preoperative evaluation' above). The operative goal is to re-establish normal anatomy. Prolonged postoperative administration of suppressive therapy helps to prevent recurrence. (See 'Postoperative medical therapy' below.)

Prevention of the formation of postoperative adhesions is discussed in detail separately. (See "Postoperative peritoneal adhesions in adults and their prevention".)

Nerve transection procedures — Nerve transection has been used to treat endometriosis-related pain at the time of surgery but is generally avoided in favor of nerve-sparing surgery [2]. As there are concerns regarding the efficacy and safety of nerve transection, nerve-sparing surgery has become the standard of care [69-72]. Several randomized trials have not shown benefit to uterosacral nerve ablation at the time of surgical management of endometriosis [73,74].

Presacral neurectomy may benefit midline pain but has the potential side effects of constipation and urinary dysfunction and thus is considered only in select cases [2,70,71]. These procedures are discussed in detail separately. (See "Chronic pelvic pain in adult females: Treatment", section on 'When to perform additional surgical procedures aimed to reduce pain'.)

Hysterectomy — Hysterectomy with or without salpingo-oophorectomy for endometriosis may be performed using any surgical approach (laparotomy, vaginal, laparoscopy, robot-assisted). When definitive surgery is performed, excision or ablation of peritoneal lesions and adhesiolysis are also typically performed. Endometriosis may cause extensive pelvic adhesions that can make hysterectomy by any route more difficult.

Endometriosis and risk of posthysterectomy complications – A retrospective, uncontrolled study assessing risks of postoperative complications after total laparoscopic hysterectomy for benign disease reported endometriosis cases having a threefold greater incidence for major postoperative complications compared with other surgical indications (odds ratio [OR] 3.51, 95% CI, 1.54-8.30) [75].

Need for future surgery – Patients who elect hysterectomy with ovarian conservation appear to have a small but increased risk for repeat surgery for endometriosis compared with those who undergo hysterectomy with bilateral oophorectomy [10,76]. (See 'Pain reduction' below.)

Full discussions of hysterectomy and oophorectomy are presented separately.

(See "Hysterectomy (benign indications): Selection of surgical route".)

(See "Oophorectomy and ovarian cystectomy".)

OUTCOMES

Surgical complications — The complications of laparoscopic treatment of endometriosis are generally the same as for other laparoscopic procedures. One study including nearly 30,000 gynecologic laparoscopies reported complications in 3 of 1894 (0.1 percent) major endometriosis-related surgeries and in 3 of 84 (3.6 percent) procedures for the treatment of deep endometriosis [17]. The most serious complications are surgical injuries to adjacent structures (eg, nerves, blood vessels, ureters) at the time of excision or ablation, wound infection, and adhesion formation.

Complications of laparoscopy and laparotomy are discussed in detail separately. (See "Complications of laparoscopic surgery" and "Complications of gynecologic surgery".)

Pain reduction — Most patients achieve initial pain relief after surgery. In a 2014 systematic review and meta-analysis of randomized trials, patients who underwent operative laparoscopy were three times more likely to report improvement in pain at 12 months than controls who underwent diagnostic laparoscopy alone (73 versus 21 percent) [8].

Return of pain and repeat surgery – The risks of recurrent pain and repeat surgery vary by the type of surgery performed (local excision versus hysterectomy, with or without ovary conservation) and the amount of elapsed time from the index surgery. Repeat surgery rates are lowest for patients who undergo hysterectomy with bilateral oophorectomy. Outcomes for conservative and definitive surgery, including oophorectomy, are discussed above. (See 'Conservative versus definitive surgery' above.)

Recurrence following conservative surgery – In a study of 423 patients with endometriosis undergoing open conservative surgery between 1967 and 1982, 62 (15 percent) underwent repeat surgery over eight years of follow-up [77]. Cumulative endometriosis recurrence rates diagnosed at the time of repeat surgery were 0.9 percent (first year from index surgery), 13.5 percent (third year from index surgery), and 40.3 percent (fifth year from index surgery).

Impact of local excision versus hysterectomy – In a different retrospective study of 420 patients with chronic pelvic pain and histologically confirmed endometriosis, the percent who had not undergone repeat surgery for pelvic pain by seven years of follow-up was highest in the hysterectomy with bilateral oophorectomy group (91.7 percent), followed by those undergoing hysterectomy with ovary conservation (77.0), and then patients undergoing local excision with ovary conservation (44.6 percent) [10]. By two years from the index surgery, repeat surgery had been performed in 20 percent of patients with prior local excision compared with 4 percent who underwent hysterectomy (with or without bilateral ovary removal).

Impact of hysterectomy with bilateral oophorectomy – While hysterectomy with oophorectomy is associated with the lowest disease recurrence and repeat surgery rate [10], that approach may not be feasible for patients who have not completed childbearing. In a retrospective review of over 4400 patients undergoing hysterectomy for endometriosis, reoperation, including for oophorectomy, was performed in 13 percent of patients undergoing hysterectomy alone versus 5 percent for those undergoing initial hysterectomy with bilateral salpingo-oophorectomy [76].

Risk factors

Surgical factors – Surgical factors associated with persistent or recurrent pain include incomplete excision of endometriosis, ovarian cyst drainage (compared with cyst excision), and ovarian conservation [76,78].

Associated factors – In a study examining the effects of underlying central nervous system sensitization, 444 patients with surgically treated endometriosis were followed for 18 months after surgery. Preoperative factors associated with reduced quality of life at postoperative follow-up included abdominal wall pain, pelvic floor myalgia, and worse Patient Health Questionnaire 9 depression scores [79].

Impact of advanced disease – Advanced disease is less likely to be fully excised at the time of surgery and thus more likely to be associated with recurrent symptoms. As an example, in a multicenter prospective cohort study, women with stage III to IV disease had a higher recurrence rate than women with stage I to II disease at two years (14 versus 6 percent, respectively) [3].

Impact of approaching menopause – Because endometriosis-related pain symptoms generally resolve with menopause, the woman's age at time of surgery impacts surgical efficacy outcomes. A longer latency to menopause allows more time for symptoms to recur. In addition, women approaching menopause may be more willing to tolerate symptoms while awaiting menopause. In a retrospective study comparing the impact of laparoscopic resection and hysterectomy on reoperation rates, the reoperation rates in the laparoscopy group declined as the patients' ages increased (hazard ratio [HR] 1.0 for women aged 19 to 29, HR 0.39 for women aged 30 to 39, and HR 0.15 for women aged 40 or older) [10]. Interestingly, increasing age did not impact the reoperation rate for women who underwent hysterectomy, with or without bilateral salpingo-oophorectomy. This finding may reflect a true reduction in symptoms following hysterectomy regardless of age or may reflect the limited remaining surgical options for these women.

Impact on fertility — The impact of surgical treatment on fertility is discussed separately. (See "Endometriosis: Treatment of infertility in females".)

POSTOPERATIVE CARE

Postoperative medical therapy — We agree with position statements from the American Society for Reproductive Medicine and European Society of Human Reproduction and Embryology advising postoperative medical suppressive therapy for most women treated surgically for endometriosis [1,2]. Long-term medical suppression, defined as at least 6 to 24 months duration, can reduce dysmenorrhea recurrence and thus avoid the need for multiple surgeries [2,80]. As discussed above, conservative surgical treatment generally does not eliminate all disease or provide lifelong pain relief. Reoperation rates increase with time [10-12]. However, multiple surgical procedures are undesirable because surgery has inherent risks, may increase adhesion formation that can cause pelvic pain, and may decrease ovarian reserve [1].

The best evidence for the efficacy of postoperative suppressive were derived from two systematic reviews: levonorgestrel-releasing intrauterine device (LNG IUD) for symptomatic endometriosis following surgery [4] and postoperative use of oral contraceptive pills for prevention of anatomical relapse or symptom recurrence after conservative surgery for endometriosis [5]. In addition, one trial reported that postoperative use of the gonadotropin-releasing hormone (GnRH) analog nafarelin significantly delayed the return of endometriosis-related symptoms compared with placebo [81]. Although a 2004 systematic review and meta-analysis of pre- and postoperative medical therapy with endometriosis surgery showed no evidence of benefit with postsurgical medical therapy, the meta-analysis had multiple limitations, including multiple drug regimens (GnRH analog, danazol, progestin, and oral contraceptive pills), variations in duration of follow-up, lack of data on time lapse to disease recurrence, the use of clinically unimportant end points (anatomic disease scores compared with patient pain scores), small sample sizes, and bias [43]. Because of these limitations and the relatively low risks of suppressive therapy, specialty societies advocate for the use of postoperative suppressive therapy until better data are available [1,2].

The options for postoperative medical therapy are the same as for initial medical therapy. Typically, first-line treatments are estrogen-progestin contraceptives or oral progestins alone [82], both of which are well-tolerated, low-risk, and cost-effective. Another option is an LNG IUD [4]. If these options are not effective, patients may be treated with other hormonal agents (eg, GnRH agonists), although these are associated with more adverse effects. Longer-term (six months) postoperative use of GnRH agonist appears to be more effective than three months of treatment for decreasing the recurrence risk of endometriosis [80]. For women with refractory pain or inadequate response, treatment with aromatase inhibitors is another option [83]. Medical therapy for endometriosis is discussed in detail separately. (See "Endometriosis: Treatment of pelvic pain", section on 'Medical treatment options'.)

Postoperative therapy following surgical treatment of an endometrioma is discussed separately. (See "Endometriosis: Management of ovarian endometriomas", section on 'Postoperative management'.)

Hormone therapy for menopause symptoms — Following bilateral oophorectomy, hormonal treatment may be necessary to treat symptoms related to surgical menopause, such as hot flushes, night sweats, and sleep disturbance. There is no strong evidence that hormone therapy should be avoided in these women. In a 2009 systematic review and meta-analysis of pain and disease recurrence in women with endometriosis who used hormone therapy for postsurgical menopause, hormone therapy was not associated with a statistical increase in pain or disease recurrence, but the number of patients was small and a clinically important difference cannot be excluded [6]. There is no outcomes-based evidence to support the addition of a progestin to prevent malignant transformation in residual endometriosis lesions [44]. The relative risks and benefits of hormone therapy may depend on the size of the endometriotic implants. Women with peritoneal disease >3 cm at the time of surgical resection had an increased risk of symptom recurrence when treated with estrogen therapy compared with women whose disease was less than 3 cm (9 versus 1 percent, respectively) in one trial [7]. However, for women with significant residual endometriosis who have either moderate or severe symptoms or are younger than 45 years of age, the benefit of hormone therapy may outweigh the risks [84].

Hormone therapy for vasomotor symptoms may be initiated immediately after surgery [85]. (See "Treatment of menopausal symptoms with hormone therapy".)

Women who have undergone hysterectomy may be treated with estrogen-only therapy; there is no advantage to adding progesterone [44].

Women with bothersome menopausal symptoms who have not undergone hysterectomy can use combined hormone therapy with low-dose estrogen (equivalent of 0.625 mg conjugated equine estrogens per day); a progestin can be used for endometrial protection, although the risk of breast cancer attributed to the progestin may be greater than the risk of endometrial cancer from the lack of progestin use [86]. If a progestin is utilized, we prefer micronized progesterone due to a lower risk of breast cancer [87].

SPECIAL ISSUES

Repeat surgery — Pelvic pain symptoms often recur after conservative surgical treatment of endometriosis (see 'Conservative versus definitive surgery' above). Repeat surgery is often performed, yet there is limited benefit from undergoing serial conservative procedures.

A patient who presents with recurrent pelvic pain following surgical treatment is evaluated to ensure that the most likely cause is endometriosis. If the patient is not on medical therapy, medical therapy is initiated and other modalities may be added (eg, pelvic physical therapy) [2]. (See "Endometriosis: Treatment of pelvic pain", section on 'Progestins'.)

Surgery may be the only option for women with severe adverse effects from hormonal therapy or for worsening pain despite hormonal treatment. Women who have already undergone conservative surgery are counseled regarding the risks and benefits of repeat conservative surgery compared with definitive surgery. (See 'Conservative versus definitive surgery' above.)

There are limited data regarding the efficacy of repeat conservative surgeries. The rate of symptom recurrence has been reported as similar to the symptom recurrence rate after an initial conservative surgery (20 to 40 percent symptom recurrence rate) [88]. Decisions regarding repeat conservative surgery must be individualized; there is no established maximum number of procedures. In our practice, we make this decision based upon patient preference and the following factors: (1) response to previous surgery (ie, the degree of symptom relief, the interval until symptoms recurred); (2) ability to tolerate medical therapy; and (3) patient age.

Extrapelvic sites

Diaphragm – Lesions on the diaphragm are usually multiple and superficial, although some penetrate deeper into the muscle (picture 1). The surgeon must be aware that these lesions can be found in the posterior portion of the diaphragm and may be obscured by the liver during laparoscopy. Placing the patient in reverse Trendelenburg position allows visualization as the liver falls away from the diaphragm. Bilateral diaphragmatic lesions are rare. Symptoms usually include catamenial referred right shoulder pain, worsening discomfort in the recumbent position, and pain with breathing. Deep lesions require full-thickness diaphragmatic resection [89]. MRI performed during menses is more sensitive in detecting diaphragmatic implants [90].

Umbilicus – Umbilical endometriosis comprises 0.5 to 1 percent of all extrapelvic disease [91]. These lesions usually occur secondary to laparoscopic surgery involving an umbilical trocar. They present as cyclic pain and bleeding within the inferior portion of the umbilicus. These lesions rarely extend through the peritoneum. Evaluation for umbilical lesions includes ultrasound, fine-needle biopsy, or magnetic resonance imaging. Surgical excision is the treatment of choice.

Abdominal wall – Abdominal wall endometriosis or a surgical site lesion (usually found in cesarean section scars) often presents as an abdominal wall mass associated with pain during menses. The endometrial tissue is superficial to the peritoneum and surgical treatment requires wide-local excision with frozen section during surgery to confirm clear margins. Surgical excision cures pain in more than 95 percent of patients [92].

Inguinal canal – Inguinal endometriotic lesions usually present as a groin lump that may cause pain during menses and even fluctuate in size with menstruation. The right groin is affected 90 percent of the time, and the location is typically close to the inguinal part of the round ligament covered by an intact peritoneum [93]. Magnetic resonance imaging or ultrasound can assist in diagnosis. Wide-local excision with concomitant laparoscopy is the treatment of choice; 91 percent of women with an inguinal lesion also have intraabdominal disease [94].

Large vessels or nerves enveloped by the disease – First-line therapy is hormonal medication.

Urinary tract – (See "Endometriosis of the bladder and ureter".)

Gastrointestinal tract – (See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)

Pulmonary – (See "Clinical features, diagnostic approach, and treatment of adults with thoracic endometriosis".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endometriosis".)

SUMMARY AND RECOMMENDATIONS

Surgical indications – Indications for surgical treatment of endometriosis include failure, refusal, or contraindications to medical therapy; histologic confirmation of endometriosis; suspicion of malignancy in an adnexal mass that has the appearance of an endometrioma; or obstruction of the urinary or intestinal tracts. (See 'General principles' above.)

Surgery is avoided in patients with incompletely evaluated pelvic pain, with persistent pelvic pain after repeated surgeries, and women nearing menopause. (See 'General principles' above.)

Conservative versus definitive surgery – Surgical treatment of endometriosis may be a conservative (eg, laparoscopic excision and/or ablation) or definitive procedure (hysterectomy with or without bilateral salpingo-oophorectomy). Conservative surgery is the first-line surgical option for most patients because it preserves fertility and hormone production, is less invasive and morbid than definitive surgery, and has documented short-term efficacy. When conservative surgery is performed, we recommend excision of lesions rather than ablation in most cases. (See 'Conservative versus definitive surgery' above.)

Definitive surgery – Definitive surgery includes hysterectomy, with or without oophorectomy. The main disadvantages of definitive surgery are the risks of surgery, loss of fertility, and symptoms of surgical menopause.

Indications for hysterectomy – We perform hysterectomy rather than conservative surgery only for women with persistent bothersome symptoms of endometriosis who do not plan future childbearing and who have failed both medical therapy and at least one conservative surgery or for women who have additional indications for hysterectomy. (See 'Conservative versus definitive surgery' above.)

Role of bilateral oophorectomy – For women undergoing hysterectomy for treatment of endometriosis, we suggest bilateral salpingo-oophorectomy ONLY for those who value decreasing the risk of reoperation more than avoiding the risks of premature menopause (Grade 2C). In general, a preference for oophorectomy is more likely as a woman approaches menopause. Oophorectomy is also reasonable for women with extensive disease involving the ovaries. (See 'Conservative versus definitive surgery' above.)

Following bilateral oophorectomy, hormonal treatment can be used to treat symptoms related to surgical menopause, such as hot flushes, night sweats, and sleep disturbance. It can be started immediately after surgery. (See 'Hormone therapy for menopause symptoms' above.)

Laparoscopy for diagnosis and treatment – Laparoscopy, particularly a first procedure, serves both a diagnostic and therapeutic purpose. The initial step is exploration of the pelvis and abdomen. Diagnosis of endometriosis by visual inspection of lesions at laparoscopy is considered satisfactory, although only histology of lesions that have been biopsied or excised can provide a definitive diagnosis. (See 'Exploration and diagnosis' above.)

Address endometriosis implants – The goal of the procedure is to destroy or remove all endometriosis implants. No single modality (ablation or excision) is superior for superficial disease. However, for deep endometriosis, excision is advised. (See 'Ablation versus excision' above.)

Relief of endometriosis-associated pain – Pain relief is achieved in approximately 75 percent of patients who undergo laparoscopic ablation or excision of endometriosis. However, the risk of recurrence is estimated to be as high as 40 percent at 10 years follow-up, and approximately 20 percent of patients will undergo additional surgery within two years. (See 'Outcomes' above.)

Postoperative medical suppressive therapy – For women surgically treated for endometriosis, we recommend postoperative medical suppressive therapy rather than no therapy (Grade 1A). (See 'Postoperative medical therapy' above.)

Considerations for repeat conservative surgery – There are limited data regarding the efficacy of repeat conservative surgeries. Factors involved in decision-making include (1) response to previous surgery (ie, the degree of symptom relief, the interval until symptoms recurred), (2) ability to tolerate medical therapy, and (3) patient age. (See 'Repeat surgery' above.)

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Topic 16673 Version 35.0

References

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