Reoperation after laparoscopic treatment of ovarian endometriomas by excision and by fenestration

FERTILITY AND STERILITY威 VOL. 72, NO. 2, AUGUST 1999 Copyright ©1999 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.

Reoperation after laparoscopic treatment of ovarian endometriomas by excision and by fenestration Ahmed Saleh, M.D., and Togas Tulandi, M.D. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada

Objective: To compare the reoperation rate after laparoscopic treatment of ovarian endometriomas by excision and by fenestration. Design: Retrospective study. Setting: University-affiliated teaching hospital. Patient(s): Two hundred thirty-one premenopausal women with ovarian endometriomas treated laparoscopically. Intervention(s): Seventy women were treated with fenestration and ablation of the cyst wall and 161 women were treated with excision. Main Outcome Measure(s): The reoperation rates of the two groups of women were evaluated using life-table analysis. Result(s): The cumulative probability of reoperation was significantly higher after fenestration than after excision. The reoperation rates at 18 months and 42 months of follow-up were 6.1% and 23.6% after excision and 21.9% and 57.8% after fenestration, respectively. In the fenestration group, the age of the patient and the diameter of the endometrioma were not associated with a higher reoperation rate. In the excision group, a larger cyst was associated with a higher reoperation rate, but age had no influence on the reoperation rate. Conclusion(s): Laparoscopic excision of ovarian endometriomas is associated with a lower reoperation rate than that of fenestration. The reoperation rate after fenestration is independent of the size of the endometrioma and the age of the patient. However, after excision, the reoperation rate is higher in those with larger cysts. (Fertil Steril威 1999;72:322– 4. ©1999 by American Society for Reproductive Medicine.) Key Words: Endometrioma, endometriosis, laparoscopy, fenestration, excision, recurrence, reoperation

Received December 11, 1998; revised and accepted March 17, 1999. Reprint requests: Togas Tulandi, M.D., McGill Reproductive Center, Women’s Pavillion, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1A1 (FAX: 514-8431496; E-mail: togas@rvhob2 .lan.mcgill.ca).

The ovary is a common site of endometriotic cysts, perhaps because it has an irregular surface that allows endometrial tissue to burrow into it, predisposing to the development of ovarian endometrioma. Endometriomas can be treated medically or surgically. However, ovarian endometriomas of ⬎1 cm do not respond favorably to medical treatment with hormonal suppression (1, 2). One half of patients may experience symptomatic improvement for a short period, but the symptoms tend to recur 6 –12 months after the cessation of treatment (3, 4). Medical treatment has no effect on pregnancy rates or recurrence rates. In contrast, surgical treatment improves symptoms for a longer period and increases pregnancy rates.

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Several studies have shown that treatment of ovarian endometriomas by laparoscopy is as

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effective or more effective than treatment by laparotomy (5, 6). In general, endometriomas are removed by excising the cyst wall. Some investigators prefer fenestration followed by ablation of the cyst wall using a laser or electrocoagulation (7–9). It is believed that this procedure is associated with minimal loss of viable ovarian cortex and less adhesion formation. The purpose of the present study was to compare the reoperation rate after laparoscopic treatment of ovarian endometriomas by excision and by fenestration.

MATERIALS AND METHODS From January 1990 to June 1997, all cases of conservative laparoscopic treatment of ovarian endometriomas at the Royal Victoria Hos-

TABLE 1 Presenting symptoms of patients who underwent laparoscopic treatment of ovarian endometriomas by fenestration and by excision. No. (%) of patients who underwent the indicated procedure

Symptom Primary infertility Secondary infertility Chronic pelvic pain Infertility and pelvic pain Pelvic mass Acute pelvic pain

Fenestration (n ⫽ 70)

Excision (n ⫽ 161)

29 (41.4) 13 (18.6) 17 (24.3) 6 (8.6) 5 (7.1) 0

65 (40.3) 27 (16.8) 40 (24.8) 17 (10.6) 8 (5.0) 4 (2.5)

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pital were reviewed. Of a total of 301 patients, 70 patients were excluded. This was due to conversion to laparotomy (n ⫽ 40), laparoscopic oophorectomy (n ⫽ 7), laparoscopic drainage only (n ⫽ 15), or loss to follow-up (n ⫽ 8). Two hundred thirty-one patients were followed up for a minimum of 12 months after the laparoscopic procedures. The presenting symptoms of the patients are shown in Table 1. The patients were divided into two groups, the fenestration group and the excision group. The fenestration group consisted of 70 patients who were treated with laparoscopic fenestration followed by ablation of the cyst wall either by laser or by electrocoagulation. The excision group consisted of 161 patients who were treated by laparoscopic excision of the endometriotic cyst. We used the revised American Fertility Society classification of endometriosis (10). Because of the retrospective nature of the study, the approval of our institutional review board was not required. The endometriotic cysts were excised mainly by the senior investigator (T.T.), and two other laparoscopic surgeons performed the fenestration procedure. In the excision group, enucleation of an intact cyst was attempted first. However, in most cases, the chocolate-colored contents of the cyst escaped. In these cases, the fluid was aspirated and the cyst wall was irrigated with normal saline solution. The internal wall of the cyst was inspected carefully and the cyst wall was stripped from the ovarian tissue by traction and countertraction using two atraumatic grasping forceps. Using this technique, we managed to excise all the endometriomas completely. The ovarian edges were inverted with light application of bipolar coagulation to the inner side of the ovarian surface approximately 1 cm from the margin. If the ovary was still gaping, the ovarian defect was approximated with a few interrupted sutures of 4-0 polydioxanone. In the fenestration group, approximately 2 cm of the cyst wall was excised and the cyst wall was destroyed with a CO2 FERTILITY & STERILITY威

laser or electrocoagulation. Other endometriotic implants were excised with scissors or coagulated with bipolar electrocoagulation. At the completion of the procedure, the abdominal cavity was irrigated liberally and 500 mL of normal saline solution was left in the pelvic cavity. Reoperation was done for recurrent endometriomas of ⬎3 cm. Data were analyzed with the Student’s t-test and life-table analysis.

RESULTS We excluded 15 patients whose endometriomas were treated only by laparoscopic aspiration. Among these patients (20 endometriomas), the recurrence rate was high (16 recurrent endometriomas [80%] at 6 months of follow-up). Among a total of 231 patients, 85 cysts were encountered in the fenestration group and 201 cysts were encountered in the excision group. Both groups were comparable in patient age, endometrioma size, and endometriosis score (Table 2). The main outcome of this study was the reoperation rate for a recurrent endometrioma in the same ovary. The mean length of follow-up was 36 months (range, 12– 48 months). The cumulative probability of reoperation was significantly higher after fenestration than after excision (Mantel-Haenszel test: P⫽.0003) (Fig. 1). Using the Cox proportional hazards model, the effects of patient age and endometrioma diameter were evaluated. In the fenestration group, patient age and endometrioma diameter were not associated with a higher reoperation rate (P ⫽ not significant). In the excision group, a larger cyst was associated with a higher reoperation rate (P⬍.01, confidence interval 1.1–1.9). The mean diameter of the endometriomas in patients who underwent reoperation was 5.3 ⫾ 1.9 cm and that in patients who did not undergo reoperation was 3.9 ⫾ 1.7 cm (P⫽.01). Patient age had no influence on the reoperation rate.

TABLE 2 Profile of patients who underwent laparoscopic treatment of ovarian endometriomas by fenestration and by excision. Procedure

Variable Mean ⫾ SD age (y) Mean ⫾ SD diameter of endometrioma (cm) No. (%) of patients with revised AFS score Stage III Stage IV

Fenestration (n ⫽ 70)

Excision (n ⫽ 161)

31.5 ⫾ 4.6

32.6 ⫾ 5.6

4.0 ⫾ 1.7

4.0 ⫾ 1.9

30 (43) 40 (57)

71 (44) 90 (56)

Note: AFS ⫽ American Fertility Society. Fertil Steril ©1999

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tissue in our series revealed the absence of follicles in all specimens.

FIGURE 1 Cumulative probability of reoperation after laparoscopic treatment of ovarian endometriomas by excision (solid line) and by fenestration (broken line). Time 0 ⫽ the day of the initial laparoscopic procedure.

It is of interest that the reoperation rate was higher after the excision of larger endometriomas. It is possible that the likelihood of leaving endometriotic tissue is greater when the cyst is large. The mean diameter of the endometriomas in the patients who underwent reoperation was 5.3 cm. In contrast, the reoperation rate after fenestration was independent of the size of the endometrioma. This suggests that regardless of the size of the endometrioma, the reoperation rate after laparoscopic fenestration is high. In our study, the reoperation rates at 18 months and 42 months of follow-up were 6.1% and 23.6% after excision and 21.9% and 57.8% after fenestration, respectively (Fig. 1). At 12 months of follow-up, the reoperation rates of both techniques were comparable. Confirming previous reports (13, 14), we found that the use of aspiration only is associated with a markedly high recurrence rate (80% at 6 months of follow-up).

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DISCUSSION In this study, the cumulative probability of reoperation was significantly lower after excision than after fenestration. This suggests that excision leads to a more complete removal of the endometriotic cyst wall. During fenestration, the cyst wall was left in situ and ablation did not seem to destroy the tissue adequately. This led to a higher reoperation rate. Our results are different from those reported by Hemmings et al. (9). This could be attributed to several factors. We studied a large number of patients, and excision was performed by one laparoscopic surgeon. Laparoscopic excision of ovarian endometriomas is technically more demanding than fenestration and ablation. Further, instead of using a crude rate, our results are reported using life-table analysis. This analysis takes into account patients who already had undergone reoperation and who were lost to follow-up at a given time. On the other hand, our findings support those in a recent prospective study that demonstrated that excision is superior to fenestration and coagulation (12). In this study, the recurrence rates of dysmenorrhea, dyspareunia, and pelvic pain were lower and the pregnancy rate was higher in the excision group than in the fenestration group. The recurrence rate of endometriomas was 6.2% in the excision group and 18.8% in the fenestration group. This is in agreement with our reoperation rate at 18 months of follow-up. The concern regarding the loss of viable ovarian tissue with excision may be unfounded. Histopathologic evaluation of the excised

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Saleh and Tulandi

We conclude that laparoscopic excision of ovarian endometriomas is associated with a lower reoperation rate than that of fenestration and ablation. The reoperation rate after fenestration and ablation is independent of the size of the endometrioma and the age of the patient. However, after excision, the reoperation rate is higher in those with larger cysts. References 1. Buttram V, Reiter R, Ward S. Treatment of endometriosis with danazol: report of a 6-year prospective study. Fertil Steril 1985;43:353– 60. 2. Shaw RW. The role of GnRH analogues in the treatment of endometriosis. Br J Obstet Gynaecol 1992;99:9 –12. 3. Schenken RS. Gonadotropin-releasing hormone analogs in the treatment of endometrioma. Am J Obstet Gynecol 1990;162:579 – 81. 4. Shaw RT. Treatment of endometriosis. Lancet 1992;340:1267–71. 5. Bateman BG, Kolp LA, Mills S. Endoscopic versus laparotomy management of endometriomas. Fertil Steril 1994;62:690 –5. 6. Catalano GF, Marana R, Caruana P, Muzii L, Mancuso S. Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate or severe endometriosis. J Am Assoc Gynecol Laparosc 1996;3:267–70. 7. Donnez J, Nisolle M, Gillet N, Semets M, Bassil S, Casanas-Roux F. Large ovarian endometrioma. Hum Reprod 1996;11:641– 6. 8. Fayez JA, Vogel MS. Comparison of different treatment methods of endometriosis by laparoscopy. Obstet Gynecol 1991;78:660 –5. 9. Hemmings R, Bissonnette F, Bouzayen R. Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation. Fertil Steril 1998;70:527–9. 10. The American Fertility Society. Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril 1985;43:351–2. 11. Ahmed MS, Barbieri RL. Reoperation rates for recurrent ovarian endometriomas after surgical excision. Gynecol Obstet Invest 1997;43: 53– 4. 12. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998;70: 1176 – 80. 13. Vercelini P, Vendola N, Bocciolone L, Colombo A, Rognoni MT, Bolis G. Laparoscopic aspiration of ovarian endometriomas. Effect with postoperative gonadotropin releasing hormone agonist treatment. J Reprod Med 1992;37:577– 80. 14. Marana R, Caruana P, Muzii L, Catalano GF, Mancuso S. Operative laparoscopy for ovarian cysts: excision versus aspiration. J Reprod Med 1996;41:435– 8.

Laparoscopic treatment of endometriomas

Vol. 72, No. 2, August 1999