**14.2 Surgical treatments**

The goal of surgery is to excise all visible endometriotic lesions and associated adhesionsperitoneal lesions, ovarian cysts, deep rectovaginal endometriosis-and to restore normal anatomy.

Laparoscopy is the gold standard for diagnosis and the primary means of treatment at this time. Laparoscopy is used with different goals such as diagnosis, ablation, excision and lysis of adhesions.

 Excisional removal of ovarian endometriomas seems superior to drainage and ablation for both improved spontaneous pregnancy rates and improved pain symptoms. Laparoscopic treatment of endometriosis carries a long-term substantial relief of symptoms for a significant percentage of women. (114) Laser ablation does not appear to be more effective than conventional electrosurgical ablation of endometriosis.

Radical procedures such as oophorectomy or total hysterectomy are indicated only in severe situations and can be performed either laparoscopically or by laparotomy. Laparotomy should be reserved for patients with advanced-stage disease who cannot undergo a laparoscopic procedure and for those in whom fertility conservation is not necessary.

Endometriosis 21

relapse of ureter endometriosis.(123) The laparoscopic approach for ureteral endometriosis is very well tolerated and has a reasonable incidence of complications, as well as a low rate

Considering the difficulty of achieving a strictly scientific approach to low disease prevalence, the surgeon dealing with ureteral endometriosis must adapt surgery to achieve a balance between conservative purposes and the risk of recurrence on the one hand, and a radical approach and risk of morbidity on the other. Ureterolysis could be used as the initial surgical step for patients with ureteral endometriosis, and may be the only treatment if the extension of ureteral involvement is limited in length and there is no residual ureteral

For patients displaying extended severe ureteral involvement, stenosis, or moderate or severe hydronephrosis with a high risk of having intrinsic ureteral disease, ureterolysis is probably insufficient and ureteroneocystostomy likely represents a wiser surgical strategy

Long-term probability of pain recurrence after repeat conservative surgery for recurrent endometriosis varies between 20 and 40%. The association of presacral neurectomy to the treatment of endometriosis might be effective in reducing midline pain; however, no studies have evaluated this procedure among patients with recurrent disease. The medium-term outcome of hysterectomy for endometriosis-associated pain is quite satisfactory; nevertheless, probability of pain persistence after hysterectomy is 15% and risk of pain worsening 3–5%, with a six times higher risk of further surgery in patients with ovarian preservation as compared to ovarian removal. The conception rate among women undergoing repetitive surgery for recurrent endometriosis associated with infertility is 26%, whereas the overall crude pregnancy rate after a primary procedure is

Repeat conservative surgery for pelvic pain associated with recurrent endometriosis has the same limitations as primary surgery, with long-term cumulative recurrence rates ranging from 20 to 40%. Conversely, only one woman out of four will conceive after repeat conservative surgery for infertility, almost half the pregnancy rate after primary surgery and

The treatment of endometriosis-related infertility is dependent on the age of the woman, the duration of infertility, the stage of endometriosis, the involvement of ovaries, tubes, or both in the endometriosis process, previous therapy, associated pain symptoms, and the priorities of the patient, taking into account her attitude toward the disease, the cost of

The success of surgery in relieving infertility is probably related to the severity of endometriosis. A recent retrospective multicenter analysis (125) reported cumulative pregnancy rates of 39%, 31%, 30%, and 25% in patients with endometriosis stages I , II, III,

Endometriosis-associated infertility can be successfully treated with intrauterine insemination, but only if it is done in combination with ovarian stimulation (126).

of recurrence.

damage or dilatation.

(124).

41%.

with no substantial advantages over IVF. (102)

treatment, her financial means, and the expected results.

and IV, respectively ,l2 months after surgical treatment.

Assisted Reproduction and Endometriosis:

In patients with severe endometriosis it has been recommended that surgical treatment be preceded by a 3-month course of medical treatment to reduce vascularization and nodular size (115).

Postoperative medical treatment is rarely indicated because it does not work based on randomized trials, because it prevents pregnancy, and the highest pregnancy rates occur during the first 6 to 12 months after conservative surgery (116, 117).

Presacral Neurectomy (PSN):

For some women, transection of presacral nerves lying within the interiliac triangle may provide relief of chronic pelvic pain. PSN is used in a limited manner and not recommended routinely for management of endometriosis related pain.

Laparoscopic presacral neurectomy can be offered to treat midline pelvic pain.(114, 118)

Deep Rectovaginal and Rectosigmoidal Endometriosis:

Surgical treatment of DIE (Deeply Infiltrating Endometriosis) requires a professional who is able to perform surgery in the gynaecological, urological, gastrointestinal and nervous structures of the pelvis, as the disease 'knows no boundaries'. There is no scientific validation either that a multispecialty team approach is superior for the treatment of bowel endometriosis, which could also make the multisurgeon model 'experimental' and therefore unethical. (119)

Preoperative laxatives, starch-free diet, and full bowel preparation are needed to allow perioperative bowel suturing, if needed. Ureter stents may be required before excision of peritoneal endometriosis surrounding the ureter. A multidisciplinary approach involving gynecologic and gastroenterologic surgeons and urologists is desirable.

Bladder endometriosis is rare .The common clinical manifestations of bladder endometriosis include menouria and urethral and pelvic pain syndrome occurring cyclically. Cystoscopy is the most useful diagnostic test with confirmation by histologic study. Treatment must be individualized according to the patient's age, desire for future pregnancies, the severity of the symptoms, the site affected, and whether other organs are involved. transurethral resection-endometrioma biopsy to confirm the diagnosis and hormone blockade with LH– RH analogues is the initial treatment most commonly used in recent years, despite an estimated recurrence of 25–35% .(120)

Analogues have been the medical treatment of choice because their introduction, and the estrogens, androgens, progestogens, and danazol used in previous years have fallen into disuse because they lead to more adverse effects. Analogues induce a postmenopause like anovulatory state, a hypogonadotropic hypogonadism with serum estrogen concentrations dropping to sterilization levels, which causes the endometrial tissue to regress. (121, 122)

Ureter endometriosis was related with reproductive tract endometriosis. It has insidious process resulting in difficulty for early diagnosis. It's important to treat pelvic deep infiltrating endometriosis and ovarian endometrioma to prevent ureter from further involvement. Post-operative treatment of pelvic endometriosis is the key point of preventing

In patients with severe endometriosis it has been recommended that surgical treatment be preceded by a 3-month course of medical treatment to reduce vascularization and nodular

Postoperative medical treatment is rarely indicated because it does not work based on randomized trials, because it prevents pregnancy, and the highest pregnancy rates occur

For some women, transection of presacral nerves lying within the interiliac triangle may provide relief of chronic pelvic pain. PSN is used in a limited manner and not recommended

Surgical treatment of DIE (Deeply Infiltrating Endometriosis) requires a professional who is able to perform surgery in the gynaecological, urological, gastrointestinal and nervous structures of the pelvis, as the disease 'knows no boundaries'. There is no scientific validation either that a multispecialty team approach is superior for the treatment of bowel endometriosis, which could also make the multisurgeon model 'experimental' and therefore

Preoperative laxatives, starch-free diet, and full bowel preparation are needed to allow perioperative bowel suturing, if needed. Ureter stents may be required before excision of peritoneal endometriosis surrounding the ureter. A multidisciplinary approach involving

Bladder endometriosis is rare .The common clinical manifestations of bladder endometriosis include menouria and urethral and pelvic pain syndrome occurring cyclically. Cystoscopy is the most useful diagnostic test with confirmation by histologic study. Treatment must be individualized according to the patient's age, desire for future pregnancies, the severity of the symptoms, the site affected, and whether other organs are involved. transurethral resection-endometrioma biopsy to confirm the diagnosis and hormone blockade with LH– RH analogues is the initial treatment most commonly used in recent years, despite an

Analogues have been the medical treatment of choice because their introduction, and the estrogens, androgens, progestogens, and danazol used in previous years have fallen into disuse because they lead to more adverse effects. Analogues induce a postmenopause like anovulatory state, a hypogonadotropic hypogonadism with serum estrogen concentrations dropping to sterilization levels, which causes the endometrial tissue to

Ureter endometriosis was related with reproductive tract endometriosis. It has insidious process resulting in difficulty for early diagnosis. It's important to treat pelvic deep infiltrating endometriosis and ovarian endometrioma to prevent ureter from further involvement. Post-operative treatment of pelvic endometriosis is the key point of preventing

gynecologic and gastroenterologic surgeons and urologists is desirable.

Laparoscopic presacral neurectomy can be offered to treat midline pelvic pain.(114, 118)

during the first 6 to 12 months after conservative surgery (116, 117).

routinely for management of endometriosis related pain.

Deep Rectovaginal and Rectosigmoidal Endometriosis:

size (115).

unethical. (119)

regress. (121, 122)

estimated recurrence of 25–35% .(120)

Presacral Neurectomy (PSN):

relapse of ureter endometriosis.(123) The laparoscopic approach for ureteral endometriosis is very well tolerated and has a reasonable incidence of complications, as well as a low rate of recurrence.

Considering the difficulty of achieving a strictly scientific approach to low disease prevalence, the surgeon dealing with ureteral endometriosis must adapt surgery to achieve a balance between conservative purposes and the risk of recurrence on the one hand, and a radical approach and risk of morbidity on the other. Ureterolysis could be used as the initial surgical step for patients with ureteral endometriosis, and may be the only treatment if the extension of ureteral involvement is limited in length and there is no residual ureteral damage or dilatation.

For patients displaying extended severe ureteral involvement, stenosis, or moderate or severe hydronephrosis with a high risk of having intrinsic ureteral disease, ureterolysis is probably insufficient and ureteroneocystostomy likely represents a wiser surgical strategy (124).

Long-term probability of pain recurrence after repeat conservative surgery for recurrent endometriosis varies between 20 and 40%. The association of presacral neurectomy to the treatment of endometriosis might be effective in reducing midline pain; however, no studies have evaluated this procedure among patients with recurrent disease. The medium-term outcome of hysterectomy for endometriosis-associated pain is quite satisfactory; nevertheless, probability of pain persistence after hysterectomy is 15% and risk of pain worsening 3–5%, with a six times higher risk of further surgery in patients with ovarian preservation as compared to ovarian removal. The conception rate among women undergoing repetitive surgery for recurrent endometriosis associated with infertility is 26%, whereas the overall crude pregnancy rate after a primary procedure is 41%.

Repeat conservative surgery for pelvic pain associated with recurrent endometriosis has the same limitations as primary surgery, with long-term cumulative recurrence rates ranging from 20 to 40%. Conversely, only one woman out of four will conceive after repeat conservative surgery for infertility, almost half the pregnancy rate after primary surgery and with no substantial advantages over IVF. (102)

Assisted Reproduction and Endometriosis:

The treatment of endometriosis-related infertility is dependent on the age of the woman, the duration of infertility, the stage of endometriosis, the involvement of ovaries, tubes, or both in the endometriosis process, previous therapy, associated pain symptoms, and the priorities of the patient, taking into account her attitude toward the disease, the cost of treatment, her financial means, and the expected results.

The success of surgery in relieving infertility is probably related to the severity of endometriosis. A recent retrospective multicenter analysis (125) reported cumulative pregnancy rates of 39%, 31%, 30%, and 25% in patients with endometriosis stages I , II, III, and IV, respectively ,l2 months after surgical treatment.

Endometriosis-associated infertility can be successfully treated with intrauterine insemination, but only if it is done in combination with ovarian stimulation (126).

Endometriosis 23

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However, there is clear evidence that the pregnancy rate in an insemination program is lower in women with endometriosis than in women with unexplained infertility. (127, 128) More recent studies that reported a normal fertilization rate but a reduced implantation rate per embryo transferred in women obtaining oocytes from donors with endometriosis (129, 130). This reduced implantation rate could be related to increased interleukin-6 levels in follicular fluid of women with endometriosis when compared with controls (131).
