Outcomes after Laparoscopic Excision of AFS Stage IIIIV Endometriosis The Waikato Experience - PowerPoint PPT Presentation

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Outcomes after Laparoscopic Excision of AFS Stage IIIIV Endometriosis The Waikato Experience

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Very few controlled studies, most data is observational data ... Preoperative preparation- bowel prep, detailed consent, written information, stoma nurse ... – PowerPoint PPT presentation

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Title: Outcomes after Laparoscopic Excision of AFS Stage IIIIV Endometriosis The Waikato Experience


1
Outcomes after Laparoscopic Excision of AFS Stage
III/IV Endometriosis -The Waikato Experience
  • Dr. Lakshmi Ravikanti
  • Mr. VP Singh
  • Waikato Hospital Hamilton and Fertility
    Associates Hamilton,
  • New Zealand

2
Excisional Surgery for Endometriosis
  • Very few controlled studies, most data is
    observational data
  • Excision of endometriosis improves endometriosis
    related pain
  • Improvement in Fertility?
  • Problems
  • Lack of description of duration of follow up and
    fecundity rates
  • Differences in surgical technique
  • Laparoscopy Vs Laparotomy
  • Increasing recognition of atypical lesions

3
ENDO-CAN
  • 241 infertile women
  • min and mild
  • endometriosis
  • Group 1- Laparoscopy
  • only
  • Group 2- Laparoscopic
  • ablation/resection
  • 36 week follow up

4
So we know that surgery for endometriosis related
infertility is useful for Stage I II but what
about Stage III IV ? Is it worth the risk in
absence of symptoms?
  • Mrs. JY
  • 34 years
  • Primary infertility 4 years
  • Regular periods, mild dysmenorrhoea, no
    dyschezia, no dyspareunia, semenalysis normal
  • Diagnostic laparoscopy- AFS Stage 3
    endometriosis, tubes normal
  • TVS- 3 cm endometrioma left ovary
  • Do you proceed to IVF or surgical treatment of
    endometriosis

5
Surgery or IVF?
Surgery
IVF
  • 30 spontaneous conception
  • Risk of surgery
  • Cost NZ 10000 (approx)
  • Recovery- 3-4 weeks
  • Is onset of symptoms a matter of time?
  • Is Oocyte Quality improved?
  • IVF conception rates 45 with one cycle and 70
    with 2 cycles
  • Cost of IVF NZ10000
  • Recovery phase/loss of productivity- minimal
  • Risk of ovarian/pelvic abscess with OPU?

6
Waikato LAPEX Study-Objectives
  • 1. Primary- To assess the efficacy of excisional
    surgery in improving pain symptoms and fertility
  • 2. Secondary- To asses the safety, recurrence
    risk histopathological correlation

7
Method
  • Retrospective study from April 2001 to December
    2007
  • Setting- tertiary public hospital and private
    practice.
  • Single surgeon (second author) or under his
    direct supervision
  • AFS grading at the time of surgery

8
Set up Technique
  • Multidisciplinary team- 2 Gynaecologists, 1
    Colorectal surgeon, Anaesthesiologist
  • Equipment- monopolar hook diathermy, bipolar
    forceps, Harmonic Scalpel, Rectal probe, RUMI
    manipulator, Endo GIA staplers
  • Preoperative preparation- bowel prep, detailed
    consent, written information, stoma nurse
  • Consistency of technique
  • Documentation- photographs and video record
  • Audit

9
lapex.avi
10
Waikato LAPEX Study- Results
39
61
11
Stage III IV- Results
  • Total no of stage III/IV endometriosis cases 306
  • Age-
  • Mean age31 years
  • Range 16-42 years (average 31)
  • Parity
  • Nulliparous-201/306 (65.7)
  • Previous hormonal treatment- 206/306 (67.3)

12
Stage III IV- Follow up
13
Stage III IV Endometriosis-Results
  • Total Completed Follow up- 270
  • Repeat Surgery- 24/270 (8.8)
  • 12/270 (4.4) had recurrent or new endometriosis
  • Two stage Surgery- 18/270 (6.7) of
  • Laparotomy- 26/270 (9.6)
  • Histological confirmation-
  • Endometriosis confirmed- 93.7
  • Endosalpingiosis- 1.1

14
Stage III/IV- Pain relief
75.6
13.3
11.1
15
Stage III IV -Pregnancy outcomes
16
Pain Infertility Group-Time to conceive in the
1st year
Pregnancy rate in 3 years- 34/88 (38.6)
17
Cumulative pregnancy rate ( Life Table approach
18
(No Transcript)
19
Additional Procedures
  • Elective bowel resection - 13
  • Partial bladder resection - 1
  • Hysterectomies - 18
  • Myomectomies - 6
  • Excision of cervical stump - 1

20
Complications
  • Major Complications
  • Rectovaginal fistula - 1
  • Intraop rectal serosal damage - 1
  • Laparotomy for Haemorrhage -2
  • Total - 4/306 (1.3)
  • Minor Complications
  • Abd wall Haematoma - 3
  • Post op fever - 4
  • Readmission with Abd pain - 6
  • UTI - 8
  • Small bowel Obst - 1

21
Conclusions
  • Pain symptoms- significantly improved
  • Fertility rate -38.6 over 3 years when
    presenting with pain infertility
  • Major complications risk is low (1.3 )
  • Is the data good enough to operate for
    infertility in absence of pain symptoms?
  • More studies needed to evaluate benefit versus
    risk of excisional surgery prior to IVF in
    asymptomatic stage III/IV endometriosis

22
Thank you
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