Laparoscopy and Endometriosis: Preventing Complications and Improving Outcomes. Luis C. Paez M.D.

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1 Laparoscopy and Endometriosis: Preventing Complications and Improving Outcomes Luis C. Paez M.D.

2 Assumptions Pelvic pain Not desiring immediate fertility H & P suggest endometriosis OC/NSAID failures Endo visualized at surgery

3 Endometriosis and Pelvic Pain Results With OCs Author Rx, Relief N Kistner, 1996 Norethynodrel 79% mg/mestranol 0.1 mg (Enovid E) Riva, 1961 Enovid E 90% 83 Riva, 1962 Enovid 69% 132 Kourides, 1968 Norgestrel 0.5 mg/ee 50µg 84% 19 Noble, 1979 Enovid E 30% 17 Kistner Various pills 83% 110

4 Hormonal Responsiveness of Endometriosis % % Metzger, et al % Compared with Eutopic Endometrium In phase % Synchronous proliferative vs secretory % 33% Compared with Other Lesions in Same Patient

5 Incidence of Endometriosis in Patients with Pelvic Pain 71% Koninckx (1991) 82% Cornillie (1990) 72% Martin (1989) 74% Koninckx (1992)

6 Staging and Pain Are Unrelated Incidence: Stage I: 40% Stage II: 24% Stage III: 24% Stage IV: 12% Fedele, et al. Stage and localization of pelvic endometriosis and pain. Fertil Steril. 1990;53:

7 Endometriosis: Types of Lesions and Pain Clear 76% Red 84% White 44% Black 22% Pain perception 1-27 mm from lesion Demco L. J Am Assoc Gynecol Laparosc

8 Possible Causes of Pelvic Pain From Endometriosis Location of lesion Depth of invasion Inflammation Stretching / scarring of tissue

9 Infiltrating Endometriosis D U D U U D V R V R V R Type I Type II Type III Koninckx, et al. Fertil Steril. 1992;58:

10 Incidence of Infiltrating Endometriosis Infiltrating endometriosis type I is suggested to be infiltration, type II retraction and type III possibly adenomyosis externa. The uterus (U), pouch of Douglas (D), vagina (V) and rectum (R) are indicated. Koninckx, et al. Fertil Steril. 1992;58: Stage I II III IV D Type I U R (N=84) V D Type II U R (N=29) V D Type III U R (N=23) V

11 Preoperative Preparation Operate in proliferative phase or suppress ovaries Consider preoperative ultrasound to identify endometriomas Bowel prep Consent for possible laparotomy

12 Intraoperative Considerations Identify anatomy Ureters Bowel Vessels Diaphragm Appendix Bladder Excision vs ablation Adhesion prevention

13 Laparoscopic Endometriosis Ablation Superficial lesion Destroy with: Laser Electrosurgery Thermal

14 Laparoscopic Endometriosis Resection Deep lesion Outline lesion Resect Check for hemostasis

15 Likely Areas of Complications Bowel injury Ureteral injury Vascular injury Inferior epigastrics Iliac vessels Great vessels Bladder injury

16 Ancillary Surgery Presacral neurectomy and LUNA Uterine suspension

17 Presacral Neurectomy

18 Issues for Presacral Neurectomy Dysmenorrhea may be primary or secondary Treating endometriosis may not cure dysmenorrhea RCT studies confirm efficacy* Can be performed by laparoscopy *Tjaden

19 Laparoscopic Presacral Neurectomy Identify promontory Identify ureter Incise over promontory Identify middle sacral artery and vein Identify presacral nerve Grasp presacral nerve Cut nerve after cautery Cauterize base of nerve Check space for additional nerve Cauterize additional nerve

20 Presacral Neurectomy Number Years Author of Patients Relief Follow-Up Chen, et al, (l-scope) 81.8% PSN 1 35 (l-scope) 57.4% LUNA 1 Candiani, (lap) PSN marked (controlled) improvement Tjaden, (lap) 88% PSN 3.4 (RCT) 9 (lap) 0% control 3.4 Perez, 1990) 25 (l-scope) 92% 1 Chen, et al, % adeno? 73% st 3 & 4 endo 75% st 1 & 2 endo 77% primary days

21 Laparoscopic Uterine Suspension

22 Issues for Uterine Suspension Dyspareunia can be caused by a symptomatic retroverted uterus or endometriosis Studies support the efficacy of uterine suspension (retrospective studies) Procedure easily performed by laparoscopy

23 Laparoscopic Uterine Suspension Retroverted uterus Identify round ligaments Divide into three segments Triple plicate the round Use three sutures Final appearance

24 Laparoscopic Uterine Suspension Number Years Author of Patients % Relief Follow-Up Gordon, % 2 Casa, % 1-5 Carter, % pain % dyspareunia 2 Koh, % dyspareunia 1-2

25 Outcomes

26 Results Following Endometrioma Surgery Number Author of Patients Failure/Recurrence Saleh, % excision (retrospect) 57.5% fenestration/ablation Beretta, month reoperative cystectomy (RCT) 9.5 months in drainage/ablation Winkel, recurrences at 6 months no leuprolide acetate (retrospect) 48 1 recurrence at 18 months with leuprolide acetate Mais, Pain significantly less with (RCT) l-scope vs lap days 0-2

27 Laparotomy vs Laparoscopy Recurrence Rates Number of Dysmenorrhea, Years Author Patients Dyspareunia, Pelvic Pain Follow-Up Crosignani, no difference 2 Busacca, no difference 2 Catalano, no difference 2 Bateman, no difference 1

28 Pain Recurrence Following Surgical Therapy % Recurrence Sutton 1994 Hornstein 1993 Redwine 1991 Howard 1993 Sutton 1990

29 Endometriosis: Results With Surgery Laser/LUNA (N=32) Diagnostic (N=31) % Improved Months 6 Months 1 Year Follow-Up Sutton, et al. 1994, 1997.

30 Endometriosis and Surgery: Results by Stage of Disease % Improved Months Follow-Up Stage I Stage II Stage III Sutton, et al. 1994, 1997.

31 Reasons for Pain Recurrence Other causes of pain besides endometriosis Residual disease Microscopic Deep Atypical Missed

32 Endometriosis: Microscopic Disease Author Results Methodology Murphy, % SEM Vasquez, % LM and SEM Nisole, % With endo LM 6% Infertility LM Redwine, % LM 66% Peritoneal pockets LM

33 Incidence of Microscopic Disease Microscopic Lesions Murphy 1986 Vasquez 1984 Nisole 1990 Redwine 1989

34 Enhancing Outcomes Postoperative medical therapy OCs Progestins Danazol GnRH agonists

35 Postoperative Medical Therapy Placebo 20 Laparotomy randomized Danazol 200 mg 20 MPA 100 mg 20 Telimaa S, et.al. Gynecol Endocrinol. 1987;1:

36 Scores of Symptoms Placebo MPA Danazol Months

37 2 Placebo Pelvic Pain Score Danazo l MPA Months

38 Time to Symptom Recurrence Post-Ablation % Patients Treated Placebo Nafarelin 57% 31% Hornstein, et al Time (Months)

39 Endometriosis: Postoperative Analog Therapy Percent Pain Free % 69% 96% 91% * 91% * 41% 60% * 23% Months Postoperative Excision Ablation Ablation + 6 Months Postoperative GnRH Agonist * P<.05 compared to ablation Winkel, et al Published % *

40 CPT Coding Laparotomy Excision of endometriosis: (special report) Vaporization of adhesions: PSN and uterine suspension: Enterolysis: Laparoscopy Vaporization of endometriosis: (special report) Enterolysis: Vaporization of adhesions: (modifier instead) PSN and uterine suspension: LUNA:

41 Conclusions Laparotomy is not a failure!! Excision, ablation or both are effective The method(s) used should be chosen based upon operator preference and experience Surgery: cytoreductive rather than curative Postoperative medical therapy recommended for pelvic pain patients with endometriosis regardless of stage

CNGOF Guidelines for the Management of Endometriosis

CNGOF Guidelines for the Management of Endometriosis Anatomoclinical forms of endometriosis Definitions Endometriosis is defined as the presence of endometrial tissue containing both glands and stroma