Surgery and the endometriosis associated-pain: A systematic review

Surgery is the most preferred modern management of endometriosis-associated pain.

Key Points

Importance:

• Surgical outcomes of endometriosis associated-pain were not reported in most of the clinical studies identified as relevant.

Highlights:

• To improve the care for women experiencing endometriosis-associated pain, a systematic and defined approach to the study of interventions is required.

What's done here:

• A systematic review of literature through Medline and Embase articles was performed to uncover the surgical results of endometriosis-associated pain.

Key results:

• Most women (77.4%) who underwent diagnostic surgery reported no reduction in pain while only a few women experienced it immediately following lesion excision, ablation, pelvic denervation or surgery for deep endometriosis.
• In the endometriotic lesion excision group, one forth of women reported some sort of remaining pain after surgery, while 10% of them had no improvement in pain.
• Patients who received lesion ablation surgery experienced fewer adverse effects when compared whose lesions were excised.
• Regarding the literature, a definite result could not be made to provide a complete pain-relief after surgery or medical treatments of endometriosis.

Lay Summary

The surgical approach for pelvic pain-related to endometriosis depends on the stage and the type of the endometriotic lesion and ranging from ablation and the excision of the lesions to radical surgery as hysterectomy with removal of ovaries and presacral neurectomy. Although in clinical research, no improvement in pain-relief after surgery reported in 20-38% of the patients, preferred conservative surgery for endometriosis remains as protection of the uterus and at least one ovary.

Singh et al. from the Department of Obstetrics and Gynecology from Ottowa Ottowa-Canada, reviewed Medline and Embase to study the articles that reported post-surgical controls of patients who underwent surgery for pain relief of endometriosis. The results are published in the "Journal of Obstetrics and  Gynecology Canada". 

Surgical outcomes after operations according to the type of surgery and location of lesions, the recurrence rate of endometriosis-associated pain, and the number of women who required further surgical approaches were investigated. The articles reporting less than 50 patients, a follow-up duration of fewer than 6 months, reports of patients who received hormonal treatment after surgery, and articles that did not investigate endometriosis-associated pain as an outcome were not included. Finally, 38 articles fere found to be sufficient and appropriate.

After lesion excision, one-fourth of patients reported having some remaining endometriosis-associated pain, and in general, more than 10% reported no improvement in pain. More than 15% of women experienced recurrent endometriosis-associated pain, and one fifth underwent further surgery.

Data did not allow a direct comparison for the efficacy of lesion excision and ablation, however, one 5-year study showed that patients were less likely to need medical therapy for endometriosis after excision than after ablation.

Assessment of reviews in this literature evaluation gives some clues about the topic as follows:

• Uterine nerve ablation did not provide better pain-relief compared to the lesion excision.
• Patients who had a hysterectomy with ovarian preservation required further operation twice, compared to the patients without ovarian preservation.
• There are limited data about the rate of patients who experienced incomplete-endometriosis associated pain reduction, pain recurrence or reoperation in literature.
• There is also no clear evidence for long-term pain relief for endometriotic patients.
• Prospective research for the long-term effects of surgery is necessary for a definitive approach for the women demanding pain relief in endometriosis.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31718952