Endometriosis Awareness Month: Shifting the Surgical Paradigm

In honor of endometriosis awareness month, the Endometriosis SIG would like to highlight the advances made for the care of patients with endometriosis in recent years:

• The publication of the Endometriosis Guidelines of the European Society of Human Reproduction and Embryology in 2022¹
• The validation of protocols for pre-operative radiographic identification/mapping of endometriosis²
• Less radical and more individualized bowel resections for deep endometriosis of the rectum³
• Advancements in the field of neuropelveology⁴
• Increased recognition of the overlapping painful conditions seen in patients with endometriosis⁵.

The SIG would like to also highlight an area for continued growth and echo the sentiments expressed by Drs. Jose Carugno, Nash Moawad, and Emad Mikhail in their call for a paradigm shift in the surgical care for patients with endometriosis⁶. 

We have evidence of the benefit of surgery for pain symptoms and fertility outcomes in certain patients, but within our field there is no clear consensus for what a surgery for endometriosis should accomplish for the patient. The lack of consensus leads to significant variation in surgical practice, a lack of preoperative planning and thus incomplete surgery and residual disease in many cases. Incomplete surgery and residual endometriosis contribute significantly to the number of repeat surgeries for what is reported as “recurrent” endometriosis. Further, incomplete surgery makes it difficult to assess the true benefit of surgery from a pain and fertility stand-point (since endometriosis is still present) and makes it impossible to evaluate the true risk of recurrence of endometriosis because recurrence and residual disease are conflated.

The best examples to support the benefit of surgery are the studies on deep endometriosis, many of which have been completed at high volume centers with surgical experts working in a multidisciplinary team. In 2019, Singh et al published a systematic review on outcomes of endometriosis surgery showing that the complete surgical management of deep endometriosis reduced VAS pain scores by 6.2 cm over a median follow-up of 22 months (11 treatment arms; n=263)⁷. In 2023, Professor Horace Roman published his series of 1,092 patients, of which 83.9% had deep endometriosis. The repeat surgery rate for the patients over 10 years of follow-up was 28%, most commonly hysterectomy for adenomyosis, followed by salpingectomy for hydrosalpinx. The rate of repeat surgery for recurrent endometriosis or pain was 9.9% over the 10 years of follow-up⁸. These findings are particularly striking when considering the historical perspective that surgery for endometriosis is futile since recurrence of disease and/or pain will occur in > 50% of patients. Rather, Dr. Singh and Professor Roman show that surgical expertise and a focus on a complete surgery reduces both pain and the risk of reoperation.

Professor Carmona and colleagues further reinforce this notion in a study of their learning curve performing advanced endometriosis surgery. They reported outcomes of their initial 60 patients undergoing laparoscopic surgery for rectovaginal endometriosis. They showed that compared to the first 30 patients, the second 30 patients had lower conversion rates, operating time, estimated blood loss, rates of incomplete excision, and rates of “recurrence.” Importantly, Dr. Carmona and colleagues showed that surgical completeness was significantly associated with “recurrence” of disease⁹.

I would like to highlight the results of these studies in honor of endometriosis awareness month and echo the calls for a paradigm shift from my colleagues. We must acknowledge that the evidence suggests that expertise in surgical care for endometriosis confers significant benefit for patients. It is time to define the standards of expertise and shift care for endometriosis to centers that meet these standards. This also involves defining an optimal surgery for endometriosis in most cases as the removal of all disease. Even if the patient does not choose this approach or the surgeon does not feel it is in the patient’s best interest, the surgeon must at least have the skill set to offer this as an option. Otherwise, we will never be able to truly understand the benefits, or lack thereof, of surgery for endometriosis.

References: 

1. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.
2. Avery JC, Deslandes A, Freger SM, Leonardi M, Lo G, Carneiro G, Condous G, Hull ML; Imagendo Study Group. Noninvasive diagnostic imaging for endometriosis part 1: a systematic review of recent developments in ultrasound, combination imaging, and artificial intelligence. Fertil Steril. 2024 Feb;121(2):164-188. doi: 10.1016/j.fertnstert.2023.12.008. Epub 2023 Dec 14. PMID: 38101562.
3. Donnez O, Roman H. Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril. 2017 Dec;108(6):931-942. doi: 10.1016/j.fertnstert.2017.09.006. PMID: 29202966.
4. Possover M. Neuropelveology: An Emerging Discipline for the Management of Pelvic Neuropathies and Bladder Dysfunctions through to Spinal Cord Injury, Anti-Ageing and the Mars Mission. J Clin Med. 2020 Oct 13;9(10):3285. doi: 10.3390/jcm9103285. PMID: 33066247; PMCID: PMC7656309.
5. Bartley EJ, Alappattu MJ, Manko K, Lewis H, Vasilopoulos T, Lamvu G. Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic-abdominal pain: A cross-sectional survey. Womens Health (Lond). 2024 Jan-Dec;20:17455057241248017. doi: 10.1177/17455057241248017. PMID: 38682290; PMCID: PMC11057341.
6. Carugno J, Moawad N, Mikhail E. Time for a paradigm shift. Fertil Steril. 2023 Oct;120(4):815-816. doi: 10.1016/j.fertnstert.2023.06.026. Epub 2023 Jun 27. PMID: 37380096.
7. Singh SS, Gude K, Perdeaux E, Gattrell WT, Becker CM. Surgical Outcomes in Patients With Endometriosis: A Systematic Review. J Obstet Gynaecol Can. 2020 Jul;42(7):881-888.e11. doi: 10.1016/j.jogc.2019.08.004. Epub 2019 Nov 9. PMID: 31718952.
8. Roman H, Chanavaz-Lacheray I, Hennetier C, Tuech JJ, Dennis T, Verspyck E, Merlot B. Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series. Fertil Steril. 2023 Oct;120(4):870-879. doi: 10.1016/j.fertnstert.2023.05.156. Epub 2023 May 22. PMID: 37225069.
9. Carmona F, Martínez-Zamora A, González X, Ginés A, Buñesch L, Balasch J. Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate? Fertil Steril. 2009 Sep;92(3):868-875. doi: 10.1016/j.fertnstert.2008.07.1738. Epub 2008 Oct 1. PMID: 18829016.