Kalra Rashi, McDonnell Rose, Stewart Fiona, Hart Roger J, Hickey Martha, Farquhar Cindy
Department of Obstetrics and Gynaecology, King Edward Memorial Hospital, Perth, Australia.
King Edward Memorial Hospital, Perth, Australia.
Cochrane Database Syst Rev. 2024 Nov 26;11(11):CD004992. doi: 10.1002/14651858.CD004992.pub4.
Endometrioma are endometriotic deposits within the ovary. Laparoscopic management of endometriomas is associated with shorter hospital stay, faster recovery, and decreased hospital costs compared with laparotomy. The previous version of this systematic review (2008), including randomised controlled trials (RCTs) of surgical interventions for endometrioma, concluded that laparoscopic cystectomy (excision) was preferable to drainage and ablation of endometrioma. We aimed to update the evidence comparing excision with drainage and ablation for improving pain and fertility-related outcomes.
To evaluate the safety and efficacy of laparoscopic excision (cystectomy) compared with laparoscopic drainage and ablation of endometrioma in women of reproductive age.
We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycInfo, two trials registries, grey literature sources, and conference proceedings on 19 December 2022. We also checked the reference lists of relevant papers and contacted leaders in the field of endoscopic surgery for any additional trials.
Eligible studies were RCTs that compared excision with drainage and ablation of endometriomas.
Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and applied the GRADE approach to rate the certainty of evidence.
We identified nine studies (involving 578 women) that investigated laparoscopic excision versus drainage and ablation of endometriomas measuring at least 3 cm in diameter. Participants were women of reproductive age who presented to an outpatient gynaecology clinic with pain, infertility, or both. For most outcomes, we downgraded the certainty of evidence for risk of bias due to lack of blinding and for imprecision due to low participant numbers. At up to two years after surgery, excisional surgery compared with ablative surgery may reduce the risk of dysmenorrhoea recurrence (OR 0.25, 95% CI 0.12 to 0.52; 2 studies, 140 women; low-certainty evidence;). Recurrence of dysmenorrhoea may occur in 49% of women after ablative surgery compared with 10% to 34% after excisional surgery. At up to two years after surgery, excisional surgery compared with ablative surgery may reduce the risk of dyspareunia recurrence (OR 0.09, 95% CI 0.03 to 0.22; 2 studies, 131 women; low-certainty evidence). Recurrence of dyspareunia may occur in 58% of women after ablative surgery compared with 4% to 23% after excisional surgery. At one year after surgery, excisional surgery may reduce the risk of endometrioma recurrence compared with ablative surgery (OR 0.17, 95% CI 0.09 to 0.34; 4 studies, 264 women; low-certainty evidence). Recurrence of endometrioma may occur in 37% of women after ablative surgery compared with 5% to 17% after excisional surgery. At one year after surgery, excisional surgery may reduce the need for further endometrioma surgery compared with ablative surgery (OR 0.16, 95% CI 0.07 to 0.41; 2 studies, 178 women; low-certainty evidence). Our results suggest that 32% of women require further endometrioma surgery after ablative surgery compared with 3% to 16% after excisional surgery. There may be little or no difference between excisional surgery and ablative surgery in terms of their effect on spontaneous pregnancy during the first year after surgery (OR 1.27, 95% CI 0.33 to 4.87; 3 studies, 101 women; low-certainty evidence). Five studies reported that there were no conversions to laparotomy. No studies provided data about any other surgical complications or adverse effects.
AUTHORS' CONCLUSIONS: Surgical management of endometrioma with excision (cystectomy) may be more effective than drainage and ablation for reducing painful menstrual periods, pain during sexual intercourse, endometrioma recurrence, and the need for further endometrioma surgery. However, there may be little or no difference between the techniques in their effect on subsequent pregnancy rates. We found limited evidence on the safety of excisional surgery compared with ablative surgery. Future trials should recruit adequate numbers of women and measure outcomes relating to adverse events and clinical pregnancy.
卵巢子宫内膜异位囊肿是卵巢内的子宫内膜异位病灶。与开腹手术相比，腹腔镜手术治疗卵巢子宫内膜异位囊肿具有住院时间短、恢复快和住院费用低的优点。本系统评价的上一版（2008年）纳入了卵巢子宫内膜异位囊肿手术干预的随机对照试验（RCT），得出结论认为腹腔镜囊肿切除术（切除）优于卵巢子宫内膜异位囊肿引流术和消融术。我们旨在更新关于切除与引流及消融术比较以改善疼痛和生育相关结局的证据。
评估腹腔镜切除（囊肿切除）术与腹腔镜引流及消融术治疗育龄期女性卵巢子宫内膜异位囊肿的安全性和有效性。
我们于2022年12月19日检索了Cochrane妇科和生育专业注册库、Cochrane系统评价数据库、医学期刊数据库、Embase、心理学文摘数据库、两个试验注册库、灰色文献来源及会议论文集。我们还查阅了相关论文的参考文献列表，并联系了内镜手术领域的专家询问是否有其他试验。
符合条件的研究为比较卵巢子宫内膜异位囊肿切除术与引流及消融术的RCT。
两位综述作者独立评估研究的纳入资格、提取数据、评估偏倚风险，并采用GRADE方法对证据的确定性进行分级。
我们纳入了9项研究（涉及578名女性），这些研究比较了腹腔镜下切除直径至少3 cm的卵巢子宫内膜异位囊肿与引流及消融术。研究对象为因疼痛、不孕或两者兼有而就诊于妇科门诊的育龄期女性。对于大多数结局，由于缺乏盲法导致的偏倚风险以及由于样本量少导致的不精确性，我们降低了证据的确定性。术后长达两年时，与消融手术相比，切除手术可能降低痛经复发风险（OR 0.25，95%CI为0.12至0.52；2项研究，140名女性；低确定性证据）。消融手术后49%的女性可能发生痛经复发，而切除手术后为10%至34%。术后长达两年时，与消融手术相比，切除手术可能降低性交痛复发风险（OR 0.09，95%CI为0.03至0.22；2项研究，131名女性；低确定性证据）。消融手术后58%的女性可能发生性交痛复发，而切除手术后为4%至23%。术后一年时，与消融手术相比，切除手术可能降低卵巢子宫内膜异位囊肿复发风险（OR 0.17，95%CI为0.09至0.34；4项研究，264名女性；低确定性证据）。消融手术后37%的女性可能发生卵巢子宫内膜异位囊肿复发，而切除手术后为5%至17%。术后一年时，与消融手术相比，切除手术可能减少进一步卵巢子宫内膜异位囊肿手术的需求（OR 0.16，95%CI为0.07至0.41；2项研究，178名女性；低确定性证据）。我们的结果表明，消融手术后32%的女性需要进一步的卵巢子宫内膜异位囊肿手术，而切除手术后为3%至16%。在术后第一年，切除手术与消融手术对自然妊娠的影响可能几乎没有差异（OR 1.27，95%CI为0.33至4.87；3项研究，101名女性；低确定性证据）。5项研究报告未转为开腹手术。没有研究提供关于任何其他手术并发症或不良反应的数据。
采用切除（囊肿切除）术治疗卵巢子宫内膜异位囊肿在减少痛经、性交痛、卵巢子宫内膜异位囊肿复发及进一步卵巢子宫内膜异位囊肿手术需求方面可能比引流及消融术更有效。然而，这些技术对后续妊娠率的影响可能几乎没有差异。与消融手术相比，我们发现关于切除手术安全性的证据有限。未来的试验应纳入足够数量的女性，并测量与不良事件和临床妊娠相关的结局。
