Endometriosis surgery: a long controversial challenge

Endometriosis is a very widespread disease, which mainly affects young women of reproductive age, causing many deleterious problems for their psycho-physical well-being. In Italy, 10–15% of women of reproductive age are affected by endometriosis and the disease generally affects about 30–50% of women who are infertile or have difficulty conceiving.

There are worldwide million women with full-blown diagnoses and women who have a mother or sister with endometriosis have a seven times greater risk of developing it.

The endometriosis peak occurs between the ages of 25 and 35, but the disease can also appear in lower age groups. The diagnosis often comes after a long and expensive journey, most of the time experienced with serious psychological repercussions for the woman. The problem of women suffering from endometriosis is the quality of life considerably deteriorated due to the related and related problems. Women with endometriosis report menstrual pain, who can be chronic and persistent, with aggravation during the menstrual period. Some women complain of asthenia and mild hyperthermia, which can be accentuated during the menstrual period, and depressive phenomena.

Pain during sexual intercourse, and at defecation, sometimes accompanied by the appearance of blood in the urine or stool, is characteristic of rectovaginal septal endometriosis, also called deep infiltrating endometriosis (DIE). At other times, pains occur during urination and are characteristic of bladder endometriosis. Endometriosis causes sub-fertility or infertility (30–40% of cases) and the impact of the disease is high and is connected to the reduction in the quality of life and direct and indirect costs.

A limited awareness of the disease is the cause of the severe diagnostic delay, estimated at around seven years.

Prompt diagnosis and prompt treatment can improve the quality of life and prevent infertility. Surgery applied to endometriosis is very complex and controversial; it can in fact have side effects capable of producing a decrease in the reproductive potential of the woman as it causes a decrease in her ovarian reserve. Endometriosis surgery is a particular surgery as it involves other organs besides the reproductive system, such as the intestine, bladder and ureters, pelvic nerves and also the upper abdominal thoracic compartment. Endometriosis surgery always includes an adequate risk/benefit assessment. Once, on the basis of the above considerations, the indication to carry out a surgical intervention has been placed, the same should be as radical as possible (complete removal of all macroscopically visible lesions) also to reduce the need for any repeated operations with the relative possible impact. It cannot be postponed in three cases: (I) intestinal stenosis with risk of sub-occlusive or occlusive phenomena; (II) ureteral stenosis with risk of impaired renal function; (III) adnexal formations with suspicious characteristics due to non-benignity. Surgical therapy of endometriosis also contemplates many complications, especially if radical or very thorough surgery is used, such as intra or post-operative hemorrhage requiring transfusion, pelviperitonitis, bowel resection risk, intestinal stenosis (narrowing of the intestine), injury ureteral or intestinal or nervous, Risk of bladder denervation (with inability to empty the bladder).

About surgical treatment, I proposed this special series, “Endometriosis Surgery”, to discuss some controversial topics about surgical treatment of endometriosis. I invited some worldwide recognized experts, form Greece, Belgium, USA, UK, Brazil, Austria and Turkey, to discuss the issue.

I have focused on the topics that always come to be discussed in conferences and congresses, which create many debates and controversies.

I proposed some topics to be addressed, as surgical instruments to be used in endometriosis surgery, the nerve sparing in endometriosis surgery, the hysteroscopy in surgical treatment, the surgical treatment in young women, the surgical treatment overall, the diagnosis tips and tricks and surgery, the surgery and the infertility related to endometriosis treatment.

The discussion of the topics by the experts will allow colleagues to draw personal opinions and conclusions on the debated arguments related to the surgical treatment of endometriosis.

Furthermore, it is hoped that the ideas reported in the special series will promote the development of new lines of research and clinical studies, which can lead to a general improvement in the surgical treatment of endometriosis.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Endometriosis Surgery”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.org/article/view/10.21037/gpm-21-37/coif). The series “Endometriosis Surgery” was commissioned by the editorial office without any funding or sponsorship. The author served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Gynecology and Pelvic Medicine from November 2019 to October 2021. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

Andrea Tinelli