When to Do Surgery and When Not to Do Surgery for Endometriosis: A Systematic Review and Meta-analysis

Endometriosis is an inflammatory disease characterized by endometrium-like lesions outside the uterus. Pelvic pain and infertility are hallmarks of the disorder. The correlation between the severity of a patient's symptoms and disease state is weak; some patients with advanced endometriosis are asymptomatic. Although some patients with endometriosis are infertile, others are not. Treatment options include both medical and surgical management. Medical alternatives include hormonal contraceptives, progestins, and gonadotropin-releasing hormone agonists or antagonists. Laparoscopic surgery consisting of excision and ablation is frequently a part of treatment. Therapeutic decision making is complex and difficult in large part due to the heterogeneous population of patients and the numerous phenotypes of endometriosis. Moreover, the setting in which health care takes place (accessibility and cost of treatment) and patient preference play large roles in treatment decisions.

The aim of this systematic review and meta-analysis was to determine whether operative laparoscopy is an effective and safe treatment for women with demonstrated endometriosis compared with alternative treatments. Other aims were to understand whether the timing of surgery affects these outcomes, to assess the risks of operative laparoscopy, and to evaluate the impact of patient preference on decision making around surgery.

To identify relevant articles, the authors conducted a search of MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. A manual search of reference lists of relevant articles and related reviews was also performed to identify articles not found by the electronic searches. All studies included were prospective, open-label randomized controlled trials (RCTs), and single-arm or observational studies. Published and unpublished studies in any language compared surgery and any alternative therapy (expectant or medical management) in patients with endometriosis, giving particular reference to timing and its impact on pain and fertility. Studies included reported on key words including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility. All original research on patient preference was considered eligible due to the anticipated absence of RCTs on this topic.

Quality of the studies ranged from moderate to very low using GRADE classification. Of the 1990 studies reviewed, 12 identified as being eligible for inclusion assessed outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies were identified that evaluated patient preferences. Operative laparoscopy was more effective than diagnostic laparoscopy (ie, expectant management) at 6 months after surgical intervention for improving overall pain (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61–4.34; P < 0.001, 2 RCTs, n = 102; low-quality evidence). Because of the very low quality of the evidence, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy appeared to offer little or no difference in clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99–1.92; P = 0.06, 4 RCTs, n = 624; moderate-quality evidence). There was no significant evidence of a difference between operative laparoscopy and diagnostic laparoscopy for surgical complications (RR, 1.98; 95% CI, 0.84–4.65; P = 0.12, 5 RCTs, n = 554, very-low-quality evidence). No studies reported on the progression of endometriosis in asymptomatic women with endometriosis to a symptomatic state or progression of anatomic disease burden (lesion volume and location). No studies were identified that directly assessed the timing of surgery for endometriosis. There were no quantitative or qualitative studies identified, which were specifically aimed at elucidating the factors contributing to a woman's choice for surgery.

These data show that operative laparoscopy may improve overall pain levels when compared with diagnostic laparoscopy, but may have little or no difference for fertility-related or adverse outcomes. There is need for high-quality RCTs comparing surgery to medical management, and these should include adverse events as an outcome. More studies are needed on patient preference in surgical decision making.