To Excise or Ablate Endometriosis? A Prospective Randomized Double-Blinded Trial After 5-Year Follow-Up

Medical therapy for patients with endometriosis often fails or produces substantial adverse effects including a contraceptive effect in women wishing to conceive. Surgery is a major treatment option for such patients. Surgical choices include ablation or excision. Surgical excision is required to fully treat severe cases with deep infiltrating endometriosis involving bowel, bladder, and other organs. Ablation is often used for mild cases. Only 2 studies have directly compared these procedures. One had a small sample size and was underpowered to show any substantial difference between the 2 techniques. The second was a retrospective study, and sound conclusions could not be drawn. The present study provides the 5-year follow-up data for a previously published prospective, randomized, double-blind trial that compared reduction of pain 1 year after laparoscopy for ablation or excision of endometriosis. Subjects were women of reproductive age with pelvic pain and visually proved endometriosis scheduled to undergo laparoscopy at a university tertiary teaching hospital between 2001 and 2007. Prior to surgery, each patient completed a questionnaire documenting symptom severity using a visual analog scale (VAS). After visual identification, eligible subjects were randomized to undergo ablation (n = 89) or excision (n = 89). The surgery was performed by obstetrics and gynecology trainees under the supervision of a consultant who would take over if necessary. After surgery, follow-up questionnaires documented pain levels every 3 months for 1 year and then every 6 months for 5 years. Symptom VAS scores over 5 years were compared in ablation and excision treatment groups. As reported previously in the 1-year study, there was no significant difference in the reduction in dyspareunia pain scores between the 2 groups. At 5 years, the reduction in dyspareunia VAS scores was significantly greater in the excision group after univariate analysis (P = 0.03) and the difference persisted after multivariate analysis (P = 0.007). More women in the ablation group than in the excision group required further medical treatment for endometriosis at 5 years (31% vs 20%; P = 0.004). These data show both laparoscopic ablation and excision provide ongoing symptom improvement in women with endometriosis for up to 5 years. Excision is more effective for severe cases with deep infiltrating endometriosis.