A better approach to the treatment of endometriosis

When I entered private practice, I soon realized that much of what I had learned about endometriosis did not make sense. Although it was taught that endometriosis was a disease of infertile women, patients with pain were almost three times more common in my private practice than were infertility patients. Also, most of the patients had already had children. When performing laparoscopy on patients with pelvic pain, I was always seeing little white, clear, or yellow lesions which neither I nor my partners could identify. I was told that they weren't endometriosis or cancer, and not to worry about them.

Better identification of endometriosis
Wanting to know more, I began to take small, tentative biopsies of these lesions through the laparoscope. Most of them came back as endometriosis! I immediately recognized the significance of this observation: Since most patients had these subtle types of lesions, and since these subtle lesions were far more common than the textbook "powder burn" lesions, our understanding of endometriosis was based on incomplete knowledge. Therefore, I could not believe all that I had been taught.

Struck by the power of surgery to reveal the truth, I reviewed the literature of 1979, and even at that time surgical excision seemed to have much more evidence of efficacy than medical therapy. Since I had not been pleased with birth control pill (BCP) therapy or Danazol in a few of my early patients, I decided early on to approach endometriosis as a purely surgical disease. If a patient had endometriosis confirmed at laparoscopy, I would immediately perform a laparotomy to excise it. As the laparoscopy biopsies got bigger and bigger, the number of laparotomies declined. Most patients seemed to have excellent pain relief with no medical therapy needed.

In the early 1980's, I decided that I would make laparoscopic excision my standard treatment, and perform laparotomy for only difficult cases.

A need for speed
As time passed, I added more and more laparoscopic skills, including laparoscopic bowel surgery, and the number of laparotomies declined further. While I was pleased with the additional surgery I could perform laparoscopically, one thing was still absent: speed. At laparotomy, I had always enjoyed an ability to complete the routine obstetrical or gynecological procedures in one-third to one-half the time taken by other surgeons. While it was apparent that laparoscopic surgery was quite complete in its effect, and the patients had a shorter recovery, I did not have the sense of forward progress during surgery that I had had at laparotomy. This led to long (up to 7 hours) procedures which were physically draining on me, the patient, and the hospital staff. I knew that surgery would have to get faster, but I didn't know how or when this would occur.

Finally, in April, 1991, I attached the monopolar electrical cord to my 3mm scissors and found what had been lacking: speed. The monopolar scissors are not used to treat endometriosis by electrocoagulation or fulguration. Excision is the only surgical method which has been shown by long term follow-up to be effective in eradicating or reducing endometriosis, and since I don't want to use unproven methods on my patients, I excise endometriosis.

Monopolar scissors allow me to cut with electricity, which is quite rapid. Since I can also dissect bluntly or sharply, rearrange the tissue, and coagulate bleeders with one instrument, instrument changes are eliminated. This has resulted in much more efficient surgery. Since a pair of scissors costs $500 and can also be used to perform laparoscopic hysterectomies, appendectomies and segmental bowel resections, this represents a significant savings over lasers which can cost up to $150,000. This will be an important method of treatment in a cost-conscious future, if hospitals and surgeons can avoid price gouging.

Excision stands up to science
Excision satisfies the demands of science by positively identifying (through biopsy) what has been removed. With laser vaporization and electrocoagulation, we have only the surgeon's opinion as to what has been destroyed and how complete that destruction was. Not all lesions turn out to be endometriosis, even when I think they may be.

Unlike laser vaporization or electrocoagulation, excision is not limited to particular areas of the pelvis. Lesions can be removed from anywhere in the body without high risk of damage to underlying vital structures. In some more difficult cases, it has been necessary to remove a quarter of the urinary bladder including the trigone, with repositioning of the ureters; in others, to remove endometriosis from the obturator nerve, or from the surface of the sacrum or ilium bones.

Specializing helps
Since my practice is restricted to endometriosis, difficult surgery is just a normal workday occurrence necessary for complete removal of disease. On the other hand, a busy obstetrician, who sees only one or two endometriosis cases a month, may lack the skill to deal with difficult endometriosis cases. For such a clinician, incomplete eradication of disease can result in repeated unnecessary and ineffective surgery for many patients. Skill in endometriosis surgery comes only with time spent in the operating room. In the last four years alone, I have spent almost 2,000 hours performing endometriosis surgery.

Laparoscopic Excision (LAPEX)
Some facts about laparoscopic excision:

  • Excision techniques and procedures are the standard surgical techniques used by all physicians at laparotomy.
  • Since standard laparoscopic instruments are used, healthcare costs can be kept at a reasonable level without any sacrifice in quality of care.
  • All excised tissue is sent to pathology to get a diagnosis. Nothing is left to chance. No assumptions are made as to what might have been excised. All abnormal tissue is removed, regardless of site.
  • Laparoscopic surgery can be used not only to excise endometriosis from any pelvic location, but also to perform appendectomies, presacral neurectomies, resection of uterosacral ligaments, excision of cysts, fibroid tumors, bowel lesions and ovaries or tubes if necessary.
  • Very dense or widespread adhesions or some bowel lesions may require laparotomy. Most surgeries begin through the laparoscope, and laparotomies are done automatically if all disease cannot be removed through the laparoscope.

Laparoscopic Excision (LAPEX) results
We know from several studies from the laparotomy era that excision has a proven record of effectiveness. Follow-up after LAPEX indicates that this favorable record can be duplicated through the laparoscope. Many types of medical or surgical therapy lack this type of long-term follow-up. Since it is very difficult to perform controlled studies of surgery, the best that can currently be done is to provide detailed follow-up of the effects of surgery on the disease.

Focus on the disease, not the symptoms
Many studies of medical or surgical therapy have focused on response of symptoms (infertility or pain) rather than response of the disease. Since symptoms can be due to other factors, (see Is my pain due to endometriosis?) this emphasis on symptoms has shifted focus from what actually happens to the disease after a treatment to what happens to the symptoms which are assumed (sometimes incorrectly) to be due to the disease. This has been done for many decades with endometriosis, and represents one of the weaknesses of its study, since response of symptoms has been regarded as indicative of response of the disease, e.g., "Since pain gets better with pregnancy or after the menopause, this means that pregnancy or menopause destroys endometriosis."

Considerations in comparing follow-up studies

  • Whereas the LAPEX study follow-up begins 6 months or more after surgery, most studies of medical therapy have ended at or within 6 months of the conclusion of treatment.
  • Ideally, studies should be corrected for patients lost to follow-up. They should also be displayed as results over time, so that a prognosis might be given at any point in time after surgery. The statistical method which satisfies this is called actuarial life table analysis.
  • For an accurate assessment of the consistency of a treatment method, sufficient numbers of patients must be followed ("the more the better").
  • Finally, quality of follow-up is a reflection of the motivation of the clinical researcher.

Endometriosis can be effectively and permanently eradicated in most patients by surgery alone
Although we don't know the true disease status of the patients who have not required reoperation, my results and those of other excision surgeons certainly indicate that endometriosis can be effectively and permanently eradicated in most patients by surgery alone. This disproves the notion that endometriosis "always comes back," that it increases in geographical extent over time, or that at best surgery is only "debulking" since "you can't remove all the disease." These notions may not only be incorrect, they also serve to hinder good surgical excision of endometriosis. To date, the only studies specifically examining the question of geographic spread of disease over time showed no increase in the amount of disease found in older age groups, which is mirrored by the lack of increasing amounts of disease in this follow-up study. Excision is a very effective form of treatment whether performed through the laparoscope or at laparotomy.

We don't know enough about endometriosis
It is apparent to most students of the disease that we simply don't know enough about endometriosis. Since many of our current problems are related to lack of biopsy-confirmation of opinions formed on the basis of clinically-observed associations, most researchers recognize the need for more biopsy control of future studies. Also, if truly effective medical therapy is ever to be developed, it will be developed in large part by study of excised specimens of disease. Therefore, surgery for endometriosis will continue to play a dominant role in the present and future study and treatment of endometriosis.