Abstract
Background The surgical treatment of endometriosis has developed in recent decades alongside the development of laparoscopic surgery and has been directed towards understanding and improving the outcomes related to fertility and pain. Little is known about the techniques and instruments actually used by gynaecological laparoscopic surgeons in relation to the evidence available. Furthermore, it is still not clear whether vaporisation or ablation of lesions is as efficacious as excision. Objectives Firstly, to internationally survey the views of gynaecologists to find out how they surgically treat endometriosis. Secondly, to determine whether excision or vaporisation is the optimal surgical technique for minimal to moderate endometriosis. Methods A 34 question web-based survey was constructed, piloted and sent out by email to the members of the BSGE, ESGE and AAGL to get a snapshot of current practice. A randomised blinded trial of harmonic scalpel excision versus carbon dioxide laser vaporisation for the treatment of minimal to moderate endometriosis in women with pelvic pain was carried out, using as a primary outcome measure EHP-30 Core pain domain, and secondary outcomes for VAS scores for dysmenorrhoea, dyspareunia, chronic pelvic pain and dyschezia, EHP-30 HRQoL measures, and HADS. Results From the survey, the predominant view is that endometriomas should be excised and that bowel resection should be avoided if possible in recto-vaginal disease. For minimal to moderate disease, superficial disease can be treated with a combination of excision or vaporisation depending on the case, but that deep disease should be excised. The trial results show that both excision and vaporisation result in an equally significant proportion of patients showing some level of pain improvement at 12 months (85. 4 v 72. 9%). However, excision results in a significantly greater extent of improvement for both superficial and deep disease than vaporisation (p=0. 008). In addition, for deep disease, the extent of improvement in pain with vaporisation is not significant (p=0. 262). Overall 20% of patients stay the same or get worse. Conclusions Excision results in greater pain and quality of life improvement than vaporisation for minimal to moderate disease, and is the optimal technique for the surgical treatment of all types of endometriosis. However it must be taken into account that the range of improvement is wide and a proportion of patients will continue to deteriorate.