When to do surgery and when not to do surgery for endometriosis : a systematic review and meta-analysis

Mathew Leonardi, Tatjana Gibbons, Mike Armour, Rui Wang, Elizabeth Glanville, Ruth Hodgson, Adele E. Cave, Jozarino Ong, Yui Yee Felice Tong, Tal Z. Jacobson, Ben W. Mol, Neil P. Johnson, George Condous

Research output: Contribution to journalArticlepeer-review

59 Citations (Scopus)

Abstract

Objective: We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis as compared to alternative treatments. We also aimed to assess the risks of operative laparoscopy as compared to alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision-making around surgery. Data Sources: We searched MEDLINE, EMBASE, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey and Web of Science from inception through May 2019. Additionally, a manual search of reference lists of relevant studies was also conducted. Methods of Study Selection: Published and unpublished randomized controlled trials (RCT) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible. Tabulation, Integration, and Results: In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies were identified as being of interest to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at six months compared to diagnostic laparoscopy (relative risk (RR), 2.65; 95% confidence interval (CI), 1.61–4.34; p < .001; 2 RCTs, 102 participants; low quality evidence). Since the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference on clinical pregnancy rates compared to diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99–1.92; p = .06; 4 RCTs, 624 participants; moderate quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared to diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84–4.65; p = .12; 5 RCTs, 554 participants; very low quality evidence). No studies reported on progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and/or locations in asymptomatic women with endometriosis. We found no studies that reported on the timing of surgery. No quantitative or qualitative studies specifically aimed at elucidating the factors informing a woman's choice for surgery were identified. Conclusion: Operative laparoscopy may improve overall pain levels, but may have little or no difference for fertility-related or adverse outcomes when compared to diagnostic laparoscopy. Additional high quality RCTs, including comparing surgery to medical management, are needed and these should also report adverse events as an outcome. Studies on patient preference in surgical decision-making are needed.
Original languageEnglish
Pages (from-to)390-407.e3
Number of pages55
JournalJournal of Minimally Invasive Gynecology
Volume27
Issue number2
DOIs
Publication statusPublished - 2020

Keywords

  • endometriosis
  • laparoscopy
  • meta-analysis
  • surgery

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