Endometriosis is a chronic estrogen-dependent disease which is defined as the localization of endometrial glandular and stromal cells outside the uterine cavity. Lifelong management should be planned with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures. Therapies for endometriosis-related symptoms including dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility are mainly a combined approach of analgesics, hormonal treatments, and surgical intervention. Due to complications and disadvantages of surgery such as risk of organ damage (especially the bowel, bladder, ureters, and blood vessels), possible reduction of ovarian reserve (eg, after ovarian cyst excision), adhesion formation, possible lack of improvements in pain or recurrence of disease/pain, necessity for the use of postoperative medical treatment to decrease recurrence, and standard surgical risks, surgical management is rarely preferred in clinical practice (1). However, non-surgical management of ovarian endometrioma may have some potential drawbacks and risks such as causing pelvic inflammatory disease or Tubo-ovarian abscesses through rupture or infection, the risk of malignant transformation later in life, and the negative impact of ovarian endometrioma on the ovarian reserve (2). Furthermore, surgical intervention has some advantages over medical treatments that provide a histologic diagnosis, allow assessment of pelvic cysts or masses with features concerning for malignancy, and reduce pain by destroying all endometriotic implants (3). There are also some specific cases where surgical intervention should be preferred, including:
- Need for tissue diagnosis of endometriosis.
- Contraindications to/or refusal of medical therapy.
- Persistent pain despite medical therapy.
- Obstruction of the bowel or urinary tract.
- Management of endometrioma rupture.
- Exclusion of malignancy especially in endometriomas having a typical appearance and growing fast.
Prior to ascribing a patient's abdominal or pelvic pain to endometriosis, the clinician should consider other important causes of such pain, including ectopic pregnancy, pelvic infection, and ovarian torsion. Patients may also have concomitant endometriosis and inflammatory bowel disease (stricturing Crohn disease). Endometriosis may be a cause for acute abdomen in women, and it should be considered in the differential diagnosis (4). The first step in such emergency cases is taking a careful anamnesis and performing a detailed physical and pelvic examination. Then hemogram and a pregnancy test should be ordered to differentiate the presence of pregnancy and pregnancy-related adverse conditions. Imaging modalities such as ultrasonography, Doppler ultrasonography, and magnetic resonance imaging can be used in differential diagnosis. Other departments such as general surgery and urology should be consulted to rule out the presence of an emergency related to the environmental organs including appendicitis, nephrolithiasis, or acute pyelonephritis.
Especially in the case of endometrioma rupture, early surgical intervention should be performed to reduce the dissemination of endometriotic cyst fluid spread, prevent adhesions, and preserve future fertility (5). If obstruction of the bowel or urinary tract occurs due to infiltration of endometriosis, urgent surgical management plays a vital role in minimalizing the loss of organ function.
Although blood tests such as serum CA125 level are not sensitive and specific for endometriosis, increased blood values of these markers during follow-up, changes in the ultrasonographic appearance of endometriomas, and aggravation of patient symptoms may also require emergency surgical intervention to rule out endometriosis-associated malignant transformation or any other serious conditions.
Deep infiltrating endometriosis is the most severe manifestation of endometriosis, affecting 20% of patients with endometriosis. It is defined as the infiltration of ectopic endometrial tissue under the peritoneum, pelvic structures, and the organ walls such as the uterosacral ligaments, colon, vagina, bladder, ureter, rectovaginal septum, and the lateral parametrium. Lateral parametrium covers the retroperitoneal connective tissue from the uterus to the lateral pelvic wall. If endometriosis spread to the parametrium, surgical intervention plays a major role in management (6). However, preoperative clinical treatment can be applied for the reduction of tissue injury and less aggressive surgical intervention (7). While disc excision is performed for single lesions, segmental resection is preferred for larger lesions or when neoplasia is a concern (8).
Surgical resection can be conservative (treatment of endometriosis by ablation or resection) or definitive (removal of all visible implants). The main objective should be therapeutic and effective surgical intervention. The potential benefits and complications should be discussed with the patient based on her age, obstetric history, desire for pregnancy, symptoms, and the characteristics and localization of the endometriotic lesions (9). Ablation is aimed to completely destroy endometrial epithelium surrounded by stroma. Excisional surgery results in a more favorable outcome than drainage and ablation regarding the recurrence of disease and symptoms, and obstetric outcomes. Ovarian cystectomy using stripping technique or combined excision/ablation technique is the preferred surgical technique compared with ablation in terms of endometrioma recurrence, pain symptoms, and increased spontaneous conception rate among subfertile patients (10). In the case of ovarian torsion due to the presence of endometrioma, detorsion of the ovary and cystectomy of the endometrioma is the most appropriate approach. Clinicians can consider hysterectomy with oophorectomy and removal of all visible endometriosis lesions in women who do not have fertility desires and have no response to other conservative therapies. It should be shared with the patient that hysterectomy is not a definitive treatment for endometriosis. Laparotomy and laparoscopy are equally effective in the treatment of endometriosis, but laparoscopic surgery appears to be superior to laparotomy due to less postoperative pain, a shorter hospital stay, and a quicker recovery and better cosmetic outcome (11*). In the case of emergency surgery for endometriosis, if the vital signs of the patient are stable, laparoscopy may be preferable. Postoperative use of hormonal therapy is recommended in patients who do not desire to become pregnant immediately after surgery (12).
Despite extensive research, the optimal management of endometriosis still remains unclear. The decision for treatment should be patient-centered and in consideration of her clinical presentation and age, symptom severity, disease extent and location, reproductive desires, other comorbidities, side effects and complications related with medical treatment and surgery, and cost (13). Relief of pain, amelioration of infertility, prevention of progression of the disease, restoration of normal anatomy, and delay of recurrence should be a priority in the management of endometriosis, even in emergency situations (14).
As a result, all women with endometriosis should be evaluated with a multidisciplinary approach considering all possibilities in differential diagnosis (15). The final decision for treatment of urgent cases should be made in a short time based on tolerability, therapeutic effectiveness, the physician’s experience, the patient’s preferences and needs, and cost.
- Flyckt R, Kim S, Falcone T. Surgical Management of Endometriosis in Patients with Chronic Pelvic Pain. Semin Reprod Med. 2017 Jan;35(1):54-64. doi: 10.1055/s-0036-1597306.
- Matsuyama R, Tsuchiya A, Nishii O. Predictive factors for emergent surgical intervention in patients with ovarian endometrioma hospitalized for pelvic inflammatory disease: A retrospective observational study. J Obstet Gynaecol Res. 2018 Feb;44(2):286-291. doi: 10.1111/jog.13513.
- Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis; a committee opinion. Fertil Steril. 2014 Apr; 101(4): 927-35.
- García León F, Ortega Díaz R, Kably Ambe A, Hernández Valencia A. Intestinal endometriosis as an acute surgical emergency. Ginecol Obstet Mex. 1997 Jul;65:287-90.
- Huang YH, Hsieh CL, Shiau CS, Lo LM, Liou JD, Chang MY. Suitable timing of surgical intervention for ruptured ovarian endometrioma. Taiwan J Obstet Gynecol. 2014 Jun;53(2):220-3. doi: 10.1016/j.tjog.2014.04.018.
- Mabrouk M, Raimondo D, Arena A, Iodice R, Altieri M, Sutherland N, Salucci P, Moro E, Seracchioli R. Parametrial Endometriosis: the Occult Condition that Makes the Hard Harder. J Minim Invasive Gynecol. 2018 Aug 31. pii: S1553-4650(18)30441-2. doi: 10.1016/j.jmig.2018.08.022.
- Bassi MA, Podgaec S, Dias Júnior JA, Sobrado CW, D Amico Filho N. Bowel endometriosis: a benign disease?.[Article in Portuguese]. Rev Assoc Med Bras (1992). 2009 Sep-Oct;55(5):611-6.
- Snyder MJ. Endometriosis. In: The ASCRS Manual of Colon and Rectal Surgery. Springer, 2014: 479-87.
- Singh SS, Suen MW. Surgery for endometriosis: beyond medical therapies. Fertil Steril. 2017 Mar;107(3):549-54.
- Cranney R, Condous G, Reid S. An update on the diagnosis, surgical management, and fertility outcomes for women with endometrioma. Acta Obstet Gynecol Scand. 2017 Jun;96(6):633-643. doi: 10.1111/aogs.13114. Epub 2017 Mar 11.
- Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum
- Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/det457. Epub 2014 Jan 15.
- Roman H. Endometriosis surgery and preservation of fertility, what surgeons should know. J Visc Surg. 2018 Jun;155 Suppl 1:S31-S36. doi: 10.1016/j.jviscsurg.2018.03.002. Epub 2018 Apr 27.
- Wullschleger MF, Imboden S, Wanner J, Mueller MD. Minimally invasive surgery when treating endometriosis has a positive effect on health and on quality of work life of affected women. Hum Reprod. 2015 Mar;30(3):553-7.
- Giudice LC, Kao LC. Endometriosis. Lancet. 2004 Nov 13-19;364(9447):1789-99.
- Ayhan A, Mao TL, Seckin T, Wu CH, Guan B, Ogawa H, Futagami M, Mizukami H, Yokoyama Y, Kurman RJ, Shih IeM. Loss of ARID1A expression is an early molecular event in tumor progression from ovarian endometriotic cyst to clear cell and endometrioid carcinoma. Int J Gynecol Cancer. 2012 Oct;22(8):1310-5.