Surgical Excision Versus Ablation for Superficial Endometriosis-Associated Pain: A Randomized Controlled Trial

The primary sequelae of endometriosis are infertility and chronic pelvic pain (CPP). Nearly 40% of women with endometriosis are infertile, and 71% to 87% have CPP. A definitive diagnosis of endometriosis can only be made with laparoscopic evaluation. Symptomatic patients, on average, see many physicians and receive a diagnosis only after 7 to 10 years. Once diagnosed, management options are limited. Menstrual suppression and painmanagement are themainstay of treatment for CPP in women with endometriosis. Surgical management also has a role in the treatment; excision and ablation surgery have been used. Although many patients and physicians believe that excision surgery will improve pain outcomes, few evidence-based data support this. Only 2 randomized studies have compared the use of excision and ablation surgery for pain management in women with endometriosis; both studies found no difference between use of excision and ablation for the treatment of CPP at the 12-month follow-up. The aim of this open-label randomized trial was to compare excision and ablation of endometriosis for the treatment of pain symptoms. The study was conducted from December 2013 to October 2014 at a single academic tertiary care hospital. Participants were reproductive-aged women with CPP or mild to moderate endometriosis planning to undergo laparoscopy. Excision or ablation of superficial endometriosis was performed at the time of robot-assisted laparoscopy. The primary outcome was a change in pain symptoms measured assessed using visual analog scale (VAS) scoring at baseline and 6 and 12 months for dysmenorrhea, nonmenstrual pain, dyspareunia, and dyschezia. Secondary outcomes were quality of life and pain scores based on the survey results at baseline and 6 and 12 months from the Short Form Health Survey, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and the International Pelvic Pain Assessment. A total of 73 patients (with endometriosis) were randomized intraoperatively: 37 to excision (excision group) and 36 to ablation (ablation group). There were no significant differences between groups in baseline patient characteristics. There was a significant improvement in dyspareunia VAS scores in the ablation group at 6 months (mean change [MC], -14.07; 95%confidence interval [CI], -25.93 to -2.21; P = 0.02), but the improvement was not maintained at 12 months. Dysmenorrhea VAS scores were reduced in the ablation group at 6 months (MC, -26.99; 95% CI, -41.48 to -12.50; P < 0.001) and 12 months (MC, -24.15; 95%CI, 39.62 to -8.68; P = 0.003). No significant change in dyspareunia VAS scoreswas found in the excision group at 6 or 12 months. The only significant difference when comparing VAS scores in the ablation and excision groups was a greater reduction in dyspareunia at 6 months in the ablation group; the MC was -22.96, with a 95% CI of -39.06 to -6.86; P = 0.01). However, this difference was not significant at 12 months. Compared with preoperative data, ablation improved dysmenorrhea at 6 and 12 months and improved dyspareunia at 6 months. However, a significant difference between ablation and excision was demonstrated only for dyspareunia. There was similar effectiveness with excision and ablation for the treatment of pain associated with superficial endometriosis, but ablation showed more significant individual changes. In management of superficial endometriosis, it is important for clinicians to carefully counsel patients regarding expectations of surgical intervention. Further long-term follow-up studies are needed.