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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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OUTCOMES
Only a small number of randomized controlled trials are available, comparing different techniques of ovarian drilling,
different energy doses, and studying few patients. This makes it difficult to give a statement on the success and short- as
well as long-term safety of this procedure.
Spontaneous ovulation is achieved in up to 70% of clomiphene-resistant or anovulatory women with hyperandrogenemia.
4
Of 165 women originally treated with ovarian drilling, 31 followed 10 years later were still ovulatory.
9
Success of spontaneous ovulation needs to be weighed against the risk for complications during surgery, postoperative
adhesion formation, and risk for diminished ovarian reserve.
Women with hyperinsulinemia,
10
luteinizing hormone greater than 10 IU/L,
11
and women with BMI less than 25 kg/m
2
12
seem to respond better than women with a BMI greater than 35 kg/m
2
, total testosterone greater than 130 ng/dL, or
infertility for greater than 3 years.
11
Pregnancy rates at 12 and 18 months after ovarian drilling for women with PCOS were 55% and 70%.
13
Unilateral ovarian drilling may be as efficacious as bilateral ovarian drilling.
14
Only one study
15
evaluated the extent of ovarian adhesion formation 4 to 6 weeks after LOD and found adhesions to be
present in 60% of patients, with more severe adhesions developing on the left ovary and amount of adhesions independent
of the number of ovarian punctures.
There are not many randomized controlled trials comparing ovarian drilling to medical treatment. Liu et al.
7
report 141
women with Clomiphene-resistant PCOS and similar baseline characteristics who underwent either 2.5 mg of letrozole up
to 6 cycles or LOD. Higher clinical pregnancy rates and life birth rates (40.8% and 38% versus 27.1% and 22.9%,
respectively) were noted in the letrozole group; however, these differences were not statistically significant, and patients
with a BMI of ≥26 were excluded from the study.
A prospective randomized trial by Abdellah
16
evaluated 140 clomiphene-resistant women with PCOS that were either
treated with 5 mg of letrozole for up to 6 cycles or underwent LOD with a monopolar diathermy needle. The author reports
an ovulation rate of 59% with letrozole versus 47.5% with LOD, and a higher pregnancy rate with letrozole (35.7% vs.
28.6%), which was not statistically significant.
A Cochrane review
17
found no significant difference in regard to clinical pregnancy, live birth, or miscarriage in women with
clomiphene-resistant PCOS who underwent LOD, compared to other medical treatments such as letrozole or
gonadotropins. There are concerns for long-term complications; however, the decreased risk for multiple gestation makes
LOD an attractive option.
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COMPLICATIONS
Complications include the general complications associated with laparoscopic surgery, in addition to the risks of decreased
ovarian reserve and adhesion formation.
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SUMMARY
There is no established standard way of performing an LOD procedure. Authors have used laser and monopolar versus
bipolar needles, at various power settings. If a standard procedure or technique could be adopted, meaningful data may be
able to be generated for comparisons to medical therapy for ovulation induction.
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KEY REFERENCES
1. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic
criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19:41–47.
2. Api M. Is ovarian reserve diminished after laparoscopic ovarian drilling? Gynecol Endocrinol. 2009;25:159–165.
3. Lebbi I, Ben Temime R, Fadhlaoui A, et al. Ovarian drilling in PCOS: is it really useful? Front Surg. 2015;2:30. ecollection
2015.
4. Daniell JF, Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril. 1989;51:232–236.
5. Muenstermann U, Kleinstein J. Long-term GnRH analogue treatment is equivalent to laparoscopic laser diathermy in
polycystic ovarian syndrome patients with severe ovarian dysfunction. Hum Reprod. 2000;15:2526–2530.
6. Gjønnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril.
1984;41:20–25.
7. Liu W, Dong S, Li Y, et al. Randomized controlled trial comparing letrozole with laparoscopic ovarian drilling in women
with clomiphene citrate-resistant polycystic ovary syndrome. Exp Ther Med. 2015;10:1297–1302.
8. Salah IM. Office microlaparoscopic ovarian drilling (OMLOD) versus conventional laparoscopic ovarian drilling (LOD)
for women with polycystic ovary syndrome. Arch Gynecol Obstet. 2013;287:361–367.
9. Gjønnaess H. Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome. Fertil Steril.
1998;69:697–701.
10. Saleh A, Morris D, Tan SL, et al. Effects of laparoscopic ovarian drilling on adrenal steroids in polycystic ovary syndrome
patients with and without hyperinsulinemia. Fertil Steril. 2001;75:501–504.
11. Amer SA, Li TC, Ledger WL. Ovulation induction using laparoscopic ovarian drilling in women with polycystic ovarian
syndrome: predictors of success. Hum Reprod. 2004;19:1719–1724.
12. Baghdadi LR, Abu Hashim H, Amer SA, et al. Impact of obesity on reproductive outcomes after ovarian ablative therapy
in PCOS: a collaborative meta-analysis. Reprod Biomed Online. 2012;25:227–241.
13. Felemban A, Tan SL, Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a
repappraisal. Fertil Steril. 2000;73:266–269.
14. Sorouri ZZ, Sharami SH, Tahersima Z, et al. Comparison between unilateral and bilateral ovarian drilling in clomiphene
citrate resistance polycystic ovary syndrome patients: a randomized clinical trial of efficacy. Int J Fertil Steril. 2015;9:1–
16.
15. Mercorio F, Mercorio A, di Spiezio Sardo A, et al. Evaluation of ovarian adhesion formation after laparoscopic ovarian
drilling by second-look minilaparoscopy. Fertil Steril. 2008;89:1229–1233.
16. Abdellah MS. Reproductive outcome after letrozole versus laparoscopic ovarian drilling for clomiphene-resistant polycystic
ovary syndrome. Int J Gynaecol Obstet. 2011;113:218–221.
17. Farquhar C, Brown J, Marjoribanks J. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory
polycystic ovary syndrome. Cochrane Database Syst Rev. 2012;(6):CD001122.
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6
Peritoneal Cavity
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Chapter 6.1
Removal of Endometrial Implants via Excision and
Vaporization
Azade h Nezhat, Lucia Di Francesco, Camr an Nezhat
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GENERAL PRINCIPLES
Definition
Endometriosis is a common chronic gynecologic disorder in which endometrial glands and stroma are present outside of the
uterus.
Endometriosis is predominantly found in the pelvis but can occur anywhere in the body.
Peritoneal endometriosis lesions may appear in different shapes and sizes. They can appear as whitish opacifications, blue-
brown or reddish-blue irregularly shaped islands or translucent blebs.
1
Symptoms of endometriosis can range from being asymptomatic to causing incapacitating pain, dysmenorrhea, dyspareunia,
and infertility.
Treatment of endometriosis depends upon severity of disease, location of ectopic lesions, desire for future childbearing, and
the goal of treatment.
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MEDICAL MANAGEMENT
Medical management includes analgesic and hormonal therapy.
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SURGICAL MANAGEMENT
Surgical treatment is either conservative or definitive.
Definitive treatment consists of hysterectomy with or without bilateral salpingo-oophorectomy.
The most common conservative surgical approach is excision, ablation, or both.
Excision is referred to removal of diseased tissue and can be performed with scissors, laser, or monopolar electrosurgery.
Ablation (vaporization) is destruction of lesion using electrocoagulation, laser, plasma energy, or an ultrasonic cutting and
coagulation device like the harmonic scalpel (Ethicon Inc., Somerville NJ).
We prefer CO
2
laser and hydrodissection for both excision and vaporization. The use of CO
2
laser, along with
hydrodissection, allows for safe surgical treatment of endometriosis over sensitive areas such as ureter and blood vessels.
2
When using CO
2
laser and hydrodissection, the fluid will provide a protective barrier between the lesion and underlying
ureter and blood vessels, as CO
2
laser does not penetrate water.
Advantages of the CO
2
laser include:
Precise application
Minimal tissue damage
Minimal risk of thermal damage to adjacent structures
Excellent hemostatic properties for small vessels.
Hydrodissection allows for:
Separation of peritoneum from underlying structures
Protecting underlying structures from penetration and potential damage by the CO
2
laser beam.
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Preoperative Planning
Patients should be counseled on both the choice between conservative or definitive surgery.
As part of the evaluation, a pelvic ultrasound should be done to detect any existing ovarian endometrioma, or a rectovaginal
or bladder nodule.
A pelvic exam that includes rectovaginal exam, palpation of uterosacral ligaments, and posterior cul-de-sac should be done.
If there is evidence of deeply infiltrative endometriosis (DIE), the bowel, ureters and bladder should be evaluated further by
either trans-rectal ultrasound (TRUS), CT scan, or MRI.
Informed consent including the risks of surgery and all alternative treatment options should be reviewed with patient.
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