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. 2024 Nov 26;11(11):CD004992.
doi: 10.1002/14651858.CD004992.pub4.

Excisional surgery versus ablative surgery for ovarian endometrioma

Rashi Kalra  1 , Rose McDonnell  2 , Fiona Stewart  3 , Roger J Hart  4 , Martha Hickey  5 , Cindy Farquhar  6
Affiliations

Excisional surgery versus ablative surgery for ovarian endometrioma

Rashi Kalra et al. Cochrane Database Syst Rev. .

Abstract

Background: Endometrioma are endometriotic deposits within the ovary. Laparoscopic management of endometriomas is associated with shorter hospital stay, faster recovery, and decreased hospital costs compared with laparotomy. The previous version of this systematic review (2008), including randomised controlled trials (RCTs) of surgical interventions for endometrioma, concluded that laparoscopic cystectomy (excision) was preferable to drainage and ablation of endometrioma. We aimed to update the evidence comparing excision with drainage and ablation for improving pain and fertility-related outcomes.

Objectives: To evaluate the safety and efficacy of laparoscopic excision (cystectomy) compared with laparoscopic drainage and ablation of endometrioma in women of reproductive age.

Search methods: We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycInfo, two trials registries, grey literature sources, and conference proceedings on 19 December 2022. We also checked the reference lists of relevant papers and contacted leaders in the field of endoscopic surgery for any additional trials.

Selection criteria: Eligible studies were RCTs that compared excision with drainage and ablation of endometriomas.

Data collection and analysis: Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and applied the GRADE approach to rate the certainty of evidence.

Main results: We identified nine studies (involving 578 women) that investigated laparoscopic excision versus drainage and ablation of endometriomas measuring at least 3 cm in diameter. Participants were women of reproductive age who presented to an outpatient gynaecology clinic with pain, infertility, or both. For most outcomes, we downgraded the certainty of evidence for risk of bias due to lack of blinding and for imprecision due to low participant numbers. At up to two years after surgery, excisional surgery compared with ablative surgery may reduce the risk of dysmenorrhoea recurrence (OR 0.25, 95% CI 0.12 to 0.52; 2 studies, 140 women; low-certainty evidence;). Recurrence of dysmenorrhoea may occur in 49% of women after ablative surgery compared with 10% to 34% after excisional surgery. At up to two years after surgery, excisional surgery compared with ablative surgery may reduce the risk of dyspareunia recurrence (OR 0.09, 95% CI 0.03 to 0.22; 2 studies, 131 women; low-certainty evidence). Recurrence of dyspareunia may occur in 58% of women after ablative surgery compared with 4% to 23% after excisional surgery. At one year after surgery, excisional surgery may reduce the risk of endometrioma recurrence compared with ablative surgery (OR 0.17, 95% CI 0.09 to 0.34; 4 studies, 264 women; low-certainty evidence). Recurrence of endometrioma may occur in 37% of women after ablative surgery compared with 5% to 17% after excisional surgery. At one year after surgery, excisional surgery may reduce the need for further endometrioma surgery compared with ablative surgery (OR 0.16, 95% CI 0.07 to 0.41; 2 studies, 178 women; low-certainty evidence). Our results suggest that 32% of women require further endometrioma surgery after ablative surgery compared with 3% to 16% after excisional surgery. There may be little or no difference between excisional surgery and ablative surgery in terms of their effect on spontaneous pregnancy during the first year after surgery (OR 1.27, 95% CI 0.33 to 4.87; 3 studies, 101 women; low-certainty evidence). Five studies reported that there were no conversions to laparotomy. No studies provided data about any other surgical complications or adverse effects.

Authors' conclusions: Surgical management of endometrioma with excision (cystectomy) may be more effective than drainage and ablation for reducing painful menstrual periods, pain during sexual intercourse, endometrioma recurrence, and the need for further endometrioma surgery. However, there may be little or no difference between the techniques in their effect on subsequent pregnancy rates. We found limited evidence on the safety of excisional surgery compared with ablative surgery. Future trials should recruit adequate numbers of women and measure outcomes relating to adverse events and clinical pregnancy.

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Conflict of interest statement

RK has no conflicts to declare. RMcD has declared an employment contract with King Edward Memorial Hospital, Western Australia. FS contributed to the review in her role as Network Support Fellow to the former Cochrane Children & Families Network. She took no part in any editorial decisions relating to this review. RJH has no conflicts to declare. MH has no conflicts to declare. CF has no conflicts to declare.

Figures

1
1
PRISMA diagram illustrating the study selection process.
2
2
Review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 1: Recurrence of pelvic pain
1.2
1.2. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 2: Recurrence of endometrioma
1.3
1.3. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 3: Requirement for further endometrioma surgery
1.4
1.4. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 4: Spontaneous pregnancy rate over the 12 months after surgery
1.5
1.5. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 5: Serum anti‐Müllerian hormone levels (ng/mL) three months after surgery (short term)
1.6
1.6. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 6: Serum anti‐Müllerian hormone levels (ng/mL) six months after surgery
1.7
1.7. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 7: Antral follicle count (number of follicles) six months after surgery
1.8
1.8. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 8: Ovarian volume (cm3) six months after surgery
1.9
1.9. Analysis
Comparison 1: Excisional surgery versus ablative surgery in the management of ovarian endometrioma by laparoscopy, Outcome 9: Ovarian response (number of dominant follicles) after surgery
See this image and copyright information in PMC

Update of

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References to studies included in this review

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Alborzi 2004 {published and unpublished data}
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References to other published versions of this review

Hart 2004
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