Update on Endometriosis Treatment by Laparoscopy
The
treatment of endometriosis today is NOT hysterectomy.
Despite
the availability of new knowledge from contemporary literature in the last five years,
many doctors still mistakenly believe that hysterectomies and oophorectomies are the cure
for endometriosis. To underscore this problem, David Redwine, MD, in a 1995 article in
Obstetrics and Gynecology, stated "Endometriosis may be unique in that it is the only
disease treated by the removal of something else."
In fact,
the correct treatment of endometriosis for pain today is the complete excision of the
endometriosis, whether it appears on the bowel, ureter, deep in the pelvis or even on the
diaphgram. The uterus and ovaries may be removed if there are other indications.
Many
women who are treated by hysterectomy / oophorectomy instead of removal of the deep pelvic
endometriosis continue to experience pain until these lesions are subsequently removed.
The experiences of Drs. Koh and Janik have mirrored that of Dr. Redwine in Oregon, where
repeat laparoscopic surgery of such women have revealed endometriosis present on bowel,
around the ureter or in other deep areas of the pelvis. In an effort to publicize new
understandings of endometriosis, the Endometriosis Association recently celebrated their
15th Anniversary in Milwaukee, where twenty world experts, including Drs. Koh and Janik,
were invited to address the international forum.
Milwaukee institute experience in endometriosis includes:
- 300 cases of severe Stage IV endometriosis in the last 5 years
- 30 women with previous hysterectomy/salpingo-oophorectomy who had persistent disease in the vault around the rectum or ureter
- 9 cases of bowel resection, associated with endometriosis
- 50 cases of partial thickness bowel wall resection associated with cul de sac endometriosis
- 50 cases of ureteric dissection
- 1 case of ureteric anastomosis, and 2 cases of stricture release of the ureter
WHAT ABOUT THE LASER?
The
laser is only effective for very superficial lesions, which generally are not the ones
responsible for incapacitating pain. Deep endometriotic lesions require excision, whether
it is by laser, electro-surgery, or scissors. Medical treatment with GNRH angonists
(Lupron, Syneral) or Danazol are ineffective for fertility in endometriosis or pain.
NO MORE HYSTERECTOMIES?
The
doctors have coined the term "radical excision of endometriosis with reproductive
preservation," which was introduced at the American Society of Reproductive Medicine
Annual Meeting in 1995 and the AAGL. In the past two years, 30 patients have come for a
second opinion, because hysterectomy had been recommended for their endometriosis related
pain. The term 'radical surgery' signified that endometriosis was aggressively removed
from all parts of the pelvis. In five cases this has necessitated colectomy/anastomosis
and 28 cases required ureteric dissection and retroperitoneal excision of periureteric
endometriosis, including the one case of ureteric anastomosis. Al1 these women had their
uterus spared, as well as their ovaries. In a one-year follow-up period, 90 percent had
significant pain improvement and of those attempting pregnancy, 11 percent achieved
pregnancy without any further treatment, 12 percent achieved pregnancy with fertility
stimulation and 30 percent achieved pregnancy by either GIFT or in Vitro Fertilization.
Thus,
radical excision of endometriosis may save the patient from multiple surgeries that
culminate in a misinformed hysterectomy and salpingo-oophorectmy.