The case for surgery for endometriosis
Medical therapy versus excision
As has been suggested in the literature, persistent emphasis on medical treatment for endometriosis may be misleading and result in physicians mismanaging their patients.9 Data indicate that little difference exists in effectiveness of the various analogs, all of which last only while the patient is undergoing treatment and most of which have negative side effects. Early disease does not disappear under suppressive treatment yet may also not progress; hence use of oral contraceptives or progestins may be successful in temporary suppression. However, in the interest of patient-centered care, the decision to use medical therapy should be made by a woman after all options have been reviewed.
All medical therapy, whether administered as first-line treatment or postoperatively, is associated with high rates of disease recurrence.10,11 Surgery, on the other hand, provides symptom reduction for up to 5 years, with studies indicating that excision is more effective than ablation. Moreover, one recent prospective, randomized, double-blind study revealed that more patients in the ablation group continued to receive medical treatment at 5 years.12 While systematic literature reviews report rates of pain recurrence as high as 50% at 1 to 2 years after surgery for symptomatic endometriosis,13 that is likely due to the nature of the surgery and the surgeon’s skill. Incomplete excision is the predominant reason for disease recurrence, with return of pain and symptoms directly correlated to surgical precision and removal of peritoneal and deeply infiltrating disease. The goal should be to eradicate disease completely in order to keep risk of recurrence as low as possible.14
The assumption that all surgery is performed by surgeons of similar caliber and experience is inaccurate, and such postulation does not address the issue of success in removing all disease at the time of surgery, ignoring the excellent results of truly skilled excisionists with adequate experience in recognition and total resection. The success of treatment indeed depends on ability to eradicate all lesions,15 and endometriosis is most likely to recur close to the original area of involvement as a result of incomplete excision or ablation.16 In experienced hands, laparoscopic surgery helps afford long-term symptomatic relief, improves pregnancy rates, and reduces recurrence of disease while largely avoiding complications.17 Complete excision is essential for improving pain and preventing disease recurrence.18