Excisional surgery versus ablative surgery for ovarian endometriomata

Background: Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured for a sit offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. Objectives: The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, with regard to relief of pain, recurrence of the endometrioma , recurrence of symptoms and the subsequent spontaneous pregnancy rate. Search strategy: The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 15 Nov 2004), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966-Nov 2004), EMBASE (1980-Nov 2004) and reference lists of articles, the hand searching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world . Selection criteria: Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata. Data collection and analysis: Reviewers assessed eligibility and trial quality. Main results: No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3 cm in size were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93), reduced requirement for further surgery (OR 0.21 CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15 CI 0.06-0.38), dyspareunia (OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56). It was also associated with a subsequent increased rate of spontaneous pregnancy women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29). Authors' conclusions: There is some evidence that excisional surgery for endometriomata provides for a more favourable out come than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However we found no data as to the effect of either approach in women who subsequently undergo assisted reproductive techniques. SYNOPSIS: Surgical removal of the ovarian cyst wall in women with endometriomata is associated with reduced recurrence of endometriomata and improved chance of pregnancy Endometriomata are benign growths of endometrial tissue with in the ovary. There is some evidence from two prospective randomised controlled trials, that surgery to excise the endometriomata leads to a more favourable outcome, compared to draining the collection and destroying the lining of the cyst with regard to recurrence of endometrioma, recurrence of symptoms and the subsequent chance of a spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. Further research is required to assess quality of life after surgery, to clarify the effect of surgery on ovarian function and fertility after IVF.