Can Controlled Trials Help Surgeons Decide on Best Way to Treat Endometriosis-Associated Pain?

Surgical randomized controlled trials may only provide limited answers about the best surgical approach to treat endometriosis pain. But they can help surgeons stay up to date with new scientific information.

Key Points

Highlights:

• Surgical randomized controlled trials have limited use when deciding on the best approach for treating endometriosis-associated pain.
• However, they can still help doctors keep up to date with new scientific advancement. 

Importance:

• Studies like this one can help surgeons keep up to date with new advances in the field of endometriosis surgery as well as help researchers design new randomized controlled trials to better test the effect of different types of surgery for the treatments of endometriosis pain. 

What's done here:

• Researchers conducted a literature search of full-text articles in English published between 1996 and October 2019 that addressed the surgical management of endometriosis-associated pain. 

Key results:

• There were 594 studies published between 1996 and 2019 that addressed the surgical management of endometriosis-associated pain. 
• 20 of the studies reported pain before and after surgery.
• Randomized controlled trials reported a substantial reduction in pain compared with no surgery in up to 80% of women.
• There was no difference in pain reduction according to the mode of surgery.
• There was limited evidence information supporting excision over ablative surgery.
• Disc excision doesn't seem to result in less complication when compared to segmental resection.
• Nerve-dividing surgery for pain may have no value for uterosacral nerve ablation and/or division and of limited value for pre-sacral neurectomy.

Lay Summary

It may not be realistic to base the decision on the best way to surgically treat pain in a woman with endometriosis on the results of surgical randomized controlled trials. This is according to a study by researchers at the Royal Hospital for Women, and the School of Women's and Children's Health at the University of New South Wales in Sydney, Australia.

However, surgeons must be willing to “accept and adopt the evidence when it does demonstrate a particular outcome," and they should “at least be open to the possibility” that their own views may be challenged and changed with new science, according to the authors. 

In order to highlight the strengths and weaknesses of randomized controlled trials that examine the surgical treatment of endometriosis-associated pelvic pain, Dr. Aaron Budden and colleagues performed a systematic review of the literature. They searched all articles published between 1996 and 2019 addressing the surgical management of endometriosis-associated pain. They then concentrated on randomized studies that reported pain before and after surgery.

Out of 594 studies that examined the surgical treatment of endometriosis between those dates, 20 reported on pain before and after surgery. In these 20 studies, up to 80% of women had substantially reduced pain when they had surgery compared to if they didn't have surgery.  However, up to a third of women in these studies also reported a placebo response where they were only operated for diagnostic purposes and not therapeutic ones.

The type of surgery, I.e., laparoscopy, laparotomy, or robot-assisted laparoscopy did not seem to make a difference to the reduction of pain. 

There was also limited evidence supporting excision over ablative surgery, which is supposed to work well only for the removal of smaller lesions.

There was also no evidence to support the hypothesis that disc excision results in fewer complications and has superior outcomes than segmental resection for bowel disease. 

Finally, the study demonstrated that surgical uterosacral nerve disruption does not improve pain.

The study is published in the Journal of Minimally Invasive Gynecology.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31712161