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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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Classification of an Endometrioma
See Table 6.2.1.
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Differential Diagnosis of an Endometrioma
Hemorrhagic ovarian cyst
Ovarian dermoid cyst: fat sequences on magnetic resonance imaging (MRI)
Cystic neoplasm
Tubo-ovarian abscess
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IMAGING AND OTHER DIAGNOSTICS
Laparoscopy is the gold standard for diagnosis of an endometrioma. Histologic confirmation of the diagnosis is
recommended.
11
Sonography appearance: Homogenous low-level internal echos (ground glass appearance), 1 to 4 compartments and no
papillary structures with detectable blood flow.
12
Color Doppler: Typical peripheral blood flow.
MRI: T1 instead of T2-weighted sequences differentiates endometrioma from mature teratoma.
13
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SURGICAL TREATMENT OF ENDOMETRIOMAS
When endometriosis is identified at laparoscopy, clinicians are recommended to surgically
14
treat it (“see and treat”) as this is
effective for reducing endometriosis-associated pain.
15
In infertile women with American Fertility Society/American Society
for Reproductive Medicine (AFS/ASRM) Stage I/II endometriosis, clinicians may consider CO
2
laser vaporization of
endometriosis, instead of monopolar electrocoagulation, since laser vaporization is associated with higher cumulative
spontaneous pregnancy rates (PR).
16
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Table 6.2.1 Classification of an Endometrioma
10
Both the presence of OMA and surgical excision of OMA appears to damage ovarian reserve. Surgery is the predominant
treatment of endometriomas. Although cystectomy increases PR, it reduces ovarian reserve.
17
Nevertheless, whether the
presence of an endometrioma adversely affects in vitro fertilization (IVF) outcomes is controversial.
18
In some hands, surgical
excision of an endometriosis (but not OMA) appeared to improve IVF outcomes.
19,20
Future research is needed to better
identify surgical techniques. Potential procedures may include aspiration with sclerotherapy and drainage with cyst wall
ablation using plasma or laser energy,
21
which may cause less ovarian damage.
Compared with women without the disease, women with OMA have a similar live birth rate although they have a lower
mean number of oocyte retrieved, require higher FSH dosage for ovarian stimulation, and have a lower AFC, suggesting that
their ovarian reserve is diminished prior to IVF. There is not one dogmatic recommendation as to whether women with OMA
should or should not have surgical intervention prior to IVF, but based on current evidence, consideration should be given to
individualize the care of these patients.
22
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Infertile Patients Who Benefit from Proceeding Directly to IVF
Older
Asymptomatic
Diminished ovarian reserve
Bilateral endometriomas
Prior surgical treatment
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Patients Who Benefit from Surgery
Younger
Pelvic pain
Intact ovarian reserve
Unilateral cysts
Sonographic features concerning for malignancy
Not planning on pursuing IVF
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PREOPERATIVE PLANNING
Considerations to take into account for the decision whether to operate on OMA:
OMA recurrence after laparoscopic excision
23
Reproductive performance lower after repetitive versus primary surgery
24
Repetitive surgery for OMA does not increase PR
25
Surgery before first IVF does not increase fertility results
26
Should women with a small endometrioma undergo an operation?
27
Delaying attempts to conceive after OMA surgery lowers PR
28
Ovarian reserve may be reduced due to surgery rather than to an OMA
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SURGICAL MANAGEMENT
Endometrioma Cystectomy
Cystectomy is a conservative surgical procedure to remove the OMA cyst.
Laparoscopic approach is preferable due to:
Lower risk of subsequent pelvic adhesions
29
Delicate nature of the repair required
Robotic assisted laparoscopic approach can be used
30,31
Technical Procedures
Stripping technique
Drainage
Fenestration and coagulation (Ablative surgery)
Combined approach
32
Stripping technique to excise large part of the cyst wall
Then using CO
2
laser on the remaining endometrioma approaching the difficult part.
14
Three-step approach (requires two laparoscopies instead of one).
9
1. Laparoscopic drainage
2. GnRH analogue for 3 months
3. Laparoscopic CO
2
laser vaporization
Meta-analysis: Stripping better than drainage or ablation for pain and recurrence.
33–35
European Society for Human Reproduction and Embryology (ESHRE) guidelines: Excision preferable than drainage and
electrocoagulation.
18,33
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Positioning
37
The patient should be placed in the normal standard dorsal lithotomy position as for other laparoscopic gynecologic procedures.
An intrauterine manipulator capable of allowing chromotubation is helpful if tubal patency is planned. Devices such as the
ClearView
®
(Clinical Innovations, Murray, UT), HUMI
®
(Cooper Surgical, Trumbull, CT), ZUMI™ (Cooper Surgical,
Trumbull, CT), or Kronner Manipulator
®
(Cooper Surgical, Trumbull, CT) allow manipulation. Saline can be used for flushing.
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