Excisional surgery versus ablative surgery for ovarian endometrioma.
Level 1 - systematic review of randomized trials
Systematic review of randomized controlled trials
PubMed 39588841 · doi:10.1002/14651858.CD004992.pub4
What was done
This Cochrane systematic review updated the evidence comparing laparoscopic excisional surgery (cystectomy) with laparoscopic drainage and ablation for endometriomas measuring at least 3 cm in reproductive-aged women presenting with pain, infertility, or both. Reviewers searched databases through December 19, 2022, included randomized controlled trials, evaluated risk of bias, and rated evidence certainty using GRADE.
What was found
Across 9 RCTs with 578 women, excisional surgery showed advantages over ablative surgery: - Dysmenorrhoea recurrence at up to 2 years: OR 0.25 (95% CI 0.12 to 0.52; 2 studies, 140 women; 10%–34% vs 49%). - Dyspareunia recurrence at up to 2 years: OR 0.09 (95% CI 0.03 to 0.22; 2 studies, 131 women; 4%–23% vs 58%). - Endometrioma recurrence at 1 year: OR 0.17 (95% CI 0.09 to 0.34; 4 studies, 264 women; 5%–17% vs 37%). - Requirement for repeat surgery at 1 year: OR 0.16 (95% CI 0.07 to 0.41; 2 studies, 178 women; 3%–16% vs 32%). - Spontaneous pregnancy within 1 year showed little to no difference: OR 1.27 (95% CI 0.33 to 4.87; 3 studies, 101 women). Five studies reported zero conversions to laparotomy, and no studies reported other adverse effects or complications.
Why it matters
Laparoscopic excision remains superior to drainage and ablation for reducing symptom recurrence, cyst recurrence, and the need for reoperation in women with ovarian endometriomas, though it does not demonstrate a clear fertility benefit.
Limits
All key outcomes were graded as low certainty due to risk of bias from unblinded designs and imprecision driven by small sample sizes. The total evidence base comprises only 578 participants across 9 trials, with individual outcome analyses containing as few as 101 to 264 women. Data on surgical complications, adverse events, and comprehensive clinical pregnancy rates were missing or inadequate.
Cited by
- supports Laparoscopic surgical resection is the gold standard for diagnosing and treating endometriosis lesions compared to ablation or burning.