Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis

Abstract

The aim of this systematic review and meta-analysis was to perform an updated analysis of the literature in regard to the surgical management of minimal to mild endometriosis. This study evaluated women of reproductive age with superficial endometriosis to determine if the results of surgical excision compared with those of ablation in improved pain scores postoperatively. Data Sources: The following databases were searched from inception to May 2020 for relevant studies: Cochrane Central Register of Controlled Trials, PubMed (MEDLINE), Ovid (MEDLINE), Scopus, and Web of Science. Methods of Study Selection: From our literature search, a total of 2633 articles were identified and screened. Ultimately, 4 randomized controlled trials were selected and included in our systematic review. The combined total number of subjects was 346 from these 4 studies, with sample sizes ranging from 24 to 170 participants. Data from 3 of the included studies were able to be compared and analyzed for a meta-analysis. The primary outcome was reduction in the visual analog scale (VAS) score for endometriosis-associated pain (dysmenorrhea, dyschezia, and dyspareunia), with follow-up time ranging from 6 to 60 months postoperatively. Tabulation, Integration, and Results: Data extracted from each study included the mean reduction in the VAS score from baseline. A random-effects model was used owing to significant heterogeneity across the studies. Statistical analyses were performed using Review Manager 5.3 software (Cochrane Collaboration, London, United Kingdom). The meta-analyses showed no significant differences between the excision and ablation groups in the mean reduction in VAS scores from baseline to 12 months postoperatively for dysmenorrhea (mean difference [MD] −0.03; 95% confidence interval [CI], −1.27 to 1.22; p = .97), dyschezia (MD 0.46; 95% CI, −1.09 to 2.02; p = .56), and dyspareunia (MD 0.10; 95% CI, −2.36 to 2.56; p = .94). In addition, there were no significant differences between the excision and ablation groups in mean VAS scores at the 12-month follow-up and beyond for dysmenorrhea (MD −0.11; 95% CI, −2.14 to 1.93; p = .92), dyschezia (MD 0.01; 95% CI, −0.70 to 0.72; p = .99), and dyspareunia (MD 0.34; 95% CI, −1.61 to 2.30; p = .73). Conclusion: On the basis of the data from our systematic review and pooled meta-analysis, no significant difference between laparoscopic excision and ablation was noted in regard to improving pain from minimal to mild endometriosis. However, to make definitive conclusions on this topic, larger randomized controlled trials are needed with longer followup.

Endometriosis in the era of precision medicine and impact on sexual and reproductive health across the lifespan and in diverse populations

“…Surgery remains a mainstay of current treatment for endometriosis 163,169–188 . In general, surgery is indicated in symptomatic patients failing, unable to tolerate or declining medical regimens, in those attempting to conceive, and/or for infertility, and to exclude malignancy in the case of an adnexal mass 117 .…”

“…From this limited amount of data, no significant difference in mean visual analog scale (VAS) was seen between excision and ablation in terms of dysmenorrhea, dyspareunia, or dyschezia. 180 A 2021 systematic review and meta-analysis of two RCTs from 2001 and 2002 of patients with mild-to-moderate stage endometriosis concluded that laparoscopic excision of endometriosis is superior to ablation in all aspects of endometriosisassociated pain including dysmenorrhea, dyspareunia, dyschezia, and chronic pelvic pain. 181 The only study with longer term follow-up by Healey in 2014 reported a double-blind randomized trial of patients with nondeeply infiltrating endometriosis followed over 5 years.…”

“…2.6.2 | Surgical therapy for endometriosis-related pelvic pain and infertility 2.6.2.1 | When to do surgery Surgery remains a mainstay of current treatment for endometriosis. 163,[169][170][171][172][173][174][175][176][177][178][179][180][181][182][183][184][185][186][187][188] In general, surgery is indicated in symptomatic patients failing, unable to tolerate or declining medical regimens, in those attempting to conceive, and/or for infertility, and to exclude malignancy in the case of an adnexal mass. 117 In general, laparoscopic or robotic surgery is favored even in the setting of advanced disease given associated shorter recovery and hospitalization, decreased cost, and safety compared to laparotomy.…”

Pathophysiology, diagnosis, and management of endometriosis

“…Little evidence shows that surgery to treat isolated superficial peritoneal endometriosis improves overall symptoms and quality of life. The uncertainty around surgical management of this subtype is compounded by the limited evidence to allow an informed selection of specific surgical modalities to remove the lesions (for example, laparoscopic ablation versus laparoscopic excision) 139140…”

Evolving best practices in the surgical management of endometriosis – examining the evidence and expert opinion

“…A 2017 meta-analysis showed improved dysmenorrhea and dysmenorrhea with excision compared to ablation for all disease stages at 12 months postoperatively [22]. A 2021 meta-analysis of patients with mild to moderate endometriosis found no difference in pain outcomes for excision versus ablation [23 ▪▪ ]. Despite a lack of robust evidence, a growing body of surgeons and patients favor excision due to concerns for incomplete treatment with ablation alone.…”