Editorial

Surgical Management of Endometriosis: Excision or Ablation

DISCUSS

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There are many ‘‘great debates’’ on the surgical manage-ment of endometriosis. The management of ovarian, bowel,and peritoneal endometriosis seems to be at the forefront ofthis contention. Specifically for the latter is whether to exciseor ablate the lesion. When there is deep involvement of adja-cent organs, there is general consensus that excision is bestfor optimal surgical outcome. However, for diseaseinvolving the peritoneum alone, there are proponents foreither option. In this issue, Healy et al [1] report on a 5-year follow-up of their initial randomized clinical trial pub-lished in 2010 [2].

In the initial study, follow-up questionnaires documentedpain levels every 3 months for 1 year. In this report, the samequestionnaires documented pain every 6 months until5 years. The study showed that excision of endometriosisprovides an advantage over ablation when treating dyspareu-nia. A further observation in this study was that ablation had1.64 times more patients requiring further medical treatmentof endometriosis. At first glance, this study supports the useof excision over ablation. It is important to note that therewas a reduction in all pain scores over the 5-year follow-up in both treatment groups.

There are some limitations to this study. Although thedesign is adequate, the study had a very high nonresponserate at year 5. A total of 88 of the 178 questionnaires werenot returned. In the end, there were 42 observations in theablation group and 40 in the excision group. Although therandomized double-blind controlled trial was believed tobe the first of its kind to have a sample size as large as 178and believed to have sufficient prior power, our concernsare with the posterior power, the sample sizes at the endpoint. Although the results did not show any significant dif-ference in the reduction of pain score between the 2 groups1 year after surgery, the reduction in sample over time is apoint of concern. Also, the continued trend toward a largerreduction with dyspareunia and pain on defecation in theexcision group at 1 year may be affected based on the char-

acteristics of the high dropouts after a year. It should also benoted that the initial groups were different despite randomi-zation. Specifically, there were more patients with deeplyinfiltrating endometriosis in the excision group than the abla-tion group (53% in the excision group and 22% in the abla-tion) group.

The study addresses secondary hypotheses for which thestudy was not designed; sample size and power were also notaddressed. The study, with its varying sample sizes, usedtests for proportions that perform best under large samplesizes. Also, the study used several tests that examined 2 vari-ables at a time rather than relying on a simultaneous effect ofmultivariable. It is important to note that both approaches toanalyzing the data are not answering the same question. Theproblem is that one is usually more interested in the multi-variable approach because it better mimics the relationshipsof covariates in life.

In summary, surgical therapy is effective at treatingendometriosis-associated pain. Although there are limita-tions in study design, this randomized double-blind clinicaltrial observed that excision is more effective than ablationwhen treating dyspareunia.

Tommaso Falcone, MDCleveland, OH

Jeffrey R. Wilson, PhDTempe, AZ

References

1. Healy M, Cheng C, Kaur H. To excise or ablate endometriosis? A pro-

spective randomized double blind trial after 5 years follow-up. J Minim

Invasive Gynecol. 2014;21(6):999–1004.

2. HealyM, AngWC, Cheng C. Surgical treatment of endometriosis: a pro-

spective randomized double blind trial comparing excision and ablation.

Fertil Steril. 2010;94:2536–2540.