Menu

Diagnosis & Therapy

Excision versus ablation during surgery for endometriosis: Expert perspective

Excision versus ablation during surgery for endometriosis: Expert perspective

BY ARNOLD P. ADVINCULA, MD

Currently, there are 2 commonly employed intraoperative techniques used to treat endometriosis: ablation and excision. When choosing a treatment approach, various factors such as surgeon preference, location of disease, and available instrumentation can impact decision-making.1 Recently, I asked Drs. Hye-Chun Hur and Douglas N. Brown their preferred tactic. Dr. Hur is Director of Minimally Invasive Gynecologic Surgery at Beth Israel Deaconess Medical Center and Assistant Professor in the Department of Obstetrics and Gynecology at Harvard Medical School in Boston, Massachusetts. Dr. Brown is Chief of Minimally Invasive Gynecologic Surgery and Director of the Center for Minimally Invasive Gynecologic Surgery in the Vincent Department of Obstetrics & Gynecology at Massachusetts General Hospital, as well as Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology, at Harvard Medical School.


Advertisement

Perspectives on Endometriosis Management


Hye-Chun Hur, MD, MPH: I am a strong advocate of excision of endometriosis. I believe that it’s essential to excise for 2 very important reasons. One reason is for diagnosis. Accurately diagnosing endometriosis through visualization alone is poor, even among gynecologic surgeons. It is very important to have an accurate diagnosis of endometriosis, since the diagnosis will then dictate the treatment for the rest of a patient’s reproductive life. The second reason that excision is essential is because you just do not know how much disease there is “behind the scenes.” When you start to excise, you begin to appreciate the depth of the disease, and often fibrosis or inflammation is present even behind the endometriosis implant that is visualized.

Douglas N. Brown, MD: I approach endometriosis in the same way that an oncologist would approach cancer. I call it cytoreduction—reducing the disease.

“There is this iceberg phenomenon, where the tip of the iceberg is seen in the water, but you have no idea how deep it actually goes. That is very much deep, infiltrative endometriosis. Performing an ablation on the top does almost nothing for the patient and may actually complicate the situation by causing scar tissue.”

Illustration: © 2018 Kimberly Martens

If a patient has symptoms, I firmly believe that you must resect the disease, whether it is on the peritoneum, bladder, bowel, or near the ureter. Now, these are radical surgeries, and not every patient should have a radical surgery. It is very much based on the patient’s pain complaints and issues at that time, but excision of endometriosis really, in my opinion, should be the standard of care.

Risks of excision of endometriosis

Dr. Brown: The risks of disease excision depend on whether a patient has ureteral disease, bladder disease, or bowel disease, suggested through a preoperative or another operative report or imaging. If this is the case, we have a preoperative discussion with the patient about, “To what extent do you want me to go to remove the disease from your pelvis? If I remove it from your peritoneum and your bladder, there is the chance that you’ll have to go home with a Foley catheter for a few days. If the bowel is involved, do you want me to try to resect the disease or shave it off the bowel? If we get into a problem, are you okay with me resecting that bowel?” These are the issues that we have to discuss, because there are potential complications, although known.

Reference

  1. Canis M, Bruhat MA, Pouly JL, Cooper MJW, Wattiez A, Manhes H. Techniques for ablation and excision of endometriosis. In: Nezhat CR, Berger GS, Nezhat FR, Buttram VC Jr, Nezhat CH, eds. Endometriosis: Advanced Management and Surgical Techniques. New York: Springer Verlag; 2012:85−94. https://link.springer.com/chapter/10.1007/978-1-4613-8404-5_10

Dr. Advincula is Vice Chair and Levine Family Professor of Women’s Health, Department of Obstetrics and Gynecology, Columbia University Medical Center; Chief of Gynecology, Sloane Hospital for Women, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York. He serves on the OBG Management Board of Editors.

Dr. Advincula reports that he serves as a consultant to ConMed, CooperSurgical, Intuitive Surgical, and Titan Medical, and receives royalties from CooperSurgical.