Editorial
Surgical Management of Endometriosis: Excision or Ablation DISCUSS
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-2-JMIG-D-14-00000
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
There are many ‘‘great debates’’ on the surgical management of endometriosis. The management of ovarian, bowel, and peritoneal endometriosis seems to be at the forefront of this contention. Specifically for the latter is whether to excise or ablate the lesion. When there is deep involvement of adjacent organs, there is general consensus that excision is best for optimal surgical outcome. However, for disease involving the peritoneum alone, there are proponents for either option. In this issue, Healy et al [1] report on a 5year follow-up of their initial randomized clinical trial published in 2010 [2]. In the initial study, follow-up questionnaires documented pain levels every 3 months for 1 year. In this report, the same questionnaires documented pain every 6 months until 5 years. The study showed that excision of endometriosis provides an advantage over ablation when treating dyspareunia. A further observation in this study was that ablation had 1.64 times more patients requiring further medical treatment of endometriosis. At first glance, this study supports the use of excision over ablation. It is important to note that there was a reduction in all pain scores over the 5-year followup in both treatment groups. There are some limitations to this study. Although the design is adequate, the study had a very high nonresponse rate at year 5. A total of 88 of the 178 questionnaires were not returned. In the end, there were 42 observations in the ablation group and 40 in the excision group. Although the randomized double-blind controlled trial was believed to be the first of its kind to have a sample size as large as 178 and believed to have sufficient prior power, our concerns are with the posterior power, the sample sizes at the end point. Although the results did not show any significant difference in the reduction of pain score between the 2 groups 1 year after surgery, the reduction in sample over time is a point of concern. Also, the continued trend toward a larger reduction with dyspareunia and pain on defecation in the excision group at 1 year may be affected based on the char1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.09.001
acteristics of the high dropouts after a year. It should also be noted that the initial groups were different despite randomization. Specifically, there were more patients with deeply infiltrating endometriosis in the excision group than the ablation group (53% in the excision group and 22% in the ablation) group. The study addresses secondary hypotheses for which the study was not designed; sample size and power were also not addressed. The study, with its varying sample sizes, used tests for proportions that perform best under large sample sizes. Also, the study used several tests that examined 2 variables at a time rather than relying on a simultaneous effect of multivariable. It is important to note that both approaches to analyzing the data are not answering the same question. The problem is that one is usually more interested in the multivariable approach because it better mimics the relationships of covariates in life. In summary, surgical therapy is effective at treating endometriosis-associated pain. Although there are limitations in study design, this randomized double-blind clinical trial observed that excision is more effective than ablation when treating dyspareunia. Tommaso Falcone, MD Cleveland, OH Jeffrey R. Wilson, PhD Tempe, AZ
References 1. Healy M, Cheng C, Kaur H. To excise or ablate endometriosis? A prospective randomized double blind trial after 5 years follow-up. J Minim Invasive Gynecol. 2014;21(6):999–1004. 2. Healy M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double blind trial comparing excision and ablation. Fertil Steril. 2010;94:2536–2540.
Surgical Management of Endometriosis: Excision or Ablation DISCUSS
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-2-JMIG-D-14-00000
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
There are many ‘‘great debates’’ on the surgical management of endometriosis. The management of ovarian, bowel, and peritoneal endometriosis seems to be at the forefront of this contention. Specifically for the latter is whether to excise or ablate the lesion. When there is deep involvement of adjacent organs, there is general consensus that excision is best for optimal surgical outcome. However, for disease involving the peritoneum alone, there are proponents for either option. In this issue, Healy et al [1] report on a 5year follow-up of their initial randomized clinical trial published in 2010 [2]. In the initial study, follow-up questionnaires documented pain levels every 3 months for 1 year. In this report, the same questionnaires documented pain every 6 months until 5 years. The study showed that excision of endometriosis provides an advantage over ablation when treating dyspareunia. A further observation in this study was that ablation had 1.64 times more patients requiring further medical treatment of endometriosis. At first glance, this study supports the use of excision over ablation. It is important to note that there was a reduction in all pain scores over the 5-year followup in both treatment groups. There are some limitations to this study. Although the design is adequate, the study had a very high nonresponse rate at year 5. A total of 88 of the 178 questionnaires were not returned. In the end, there were 42 observations in the ablation group and 40 in the excision group. Although the randomized double-blind controlled trial was believed to be the first of its kind to have a sample size as large as 178 and believed to have sufficient prior power, our concerns are with the posterior power, the sample sizes at the end point. Although the results did not show any significant difference in the reduction of pain score between the 2 groups 1 year after surgery, the reduction in sample over time is a point of concern. Also, the continued trend toward a larger reduction with dyspareunia and pain on defecation in the excision group at 1 year may be affected based on the char1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.09.001
acteristics of the high dropouts after a year. It should also be noted that the initial groups were different despite randomization. Specifically, there were more patients with deeply infiltrating endometriosis in the excision group than the ablation group (53% in the excision group and 22% in the ablation) group. The study addresses secondary hypotheses for which the study was not designed; sample size and power were also not addressed. The study, with its varying sample sizes, used tests for proportions that perform best under large sample sizes. Also, the study used several tests that examined 2 variables at a time rather than relying on a simultaneous effect of multivariable. It is important to note that both approaches to analyzing the data are not answering the same question. The problem is that one is usually more interested in the multivariable approach because it better mimics the relationships of covariates in life. In summary, surgical therapy is effective at treating endometriosis-associated pain. Although there are limitations in study design, this randomized double-blind clinical trial observed that excision is more effective than ablation when treating dyspareunia. Tommaso Falcone, MD Cleveland, OH Jeffrey R. Wilson, PhD Tempe, AZ
References 1. Healy M, Cheng C, Kaur H. To excise or ablate endometriosis? A prospective randomized double blind trial after 5 years follow-up. J Minim Invasive Gynecol. 2014;21(6):999–1004. 2. Healy M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double blind trial comparing excision and ablation. Fertil Steril. 2010;94:2536–2540.
