Why Excision Is Better than Ablation for Endometriosis Treatment

excision vs ablation

Louise van der Does, PhD, CIGC Director of Research

Endometriosis occurs when cells that make up the lining of the uterus begin to travel and grow outside the uterus. These lesions can implant on any of the surrounding organs — such as the ovaries, fallopian tubes, bowel or bladder — and cause severe pain. Endometriosis can only be definitively diagnosed through laparoscopic surgery. This can determine a patient’s stage of endometriosis as well as where the lesions are located, and it can rule out conditions that share similar symptoms. 

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Some physicians may suggest medication, birth control or another nonsurgical method to manage endometriosis symptoms, but these methods may only temporarily mask symptoms. Surgery to remove the lesions is more likely to result in more complete relief. The two most common surgical treatments for endometriosis removal are excision and ablation, but one is a far superior treatment to the other.

Endometriosis Ablation: The Downsides of Burning

Ablation for endometriosis is a limited superficial treatment that involves burning the lesions to remove them. This is also commonly referred to as fulguration, coagulation or cauterization. The problem with this technique is it only chars the surface of the lesion. Endometriosis lesions can implant deep in pelvic organs, meaning if only the top of the lesion is being burned off, the roots remain. Failing to remove those roots makes the chances of recurrence much more likely.

Research² shows high rates of recurrence for non-excisional surgery, including ablation. Those recurrence rates generally rise to between 40% and 60% as quickly as one to two years after the initial ablation surgery2. Recurrence may make a second surgery necessary to relieve ongoing symptoms, and research has shown endometriosis often regrows at the original area of involvement. This means it’s likely the recurrence was due to incomplete removal of the original lesions found during the first procedure. Any amount of leftover endometriosis can continue to cause pain and other severe symptoms, no matter how small the lesions may be.

Ablation is also not recommended for patients who desire future fertility. Burning any tissue in the pelvic region, especially near the ovaries, can create scar tissue and is associated with poor fertility outcomes. In cases where endometriosis occurs directly on one or both ovaries, an experienced surgeon may perform a combination of minimal ablative and excisional techniques to remove the disease while avoiding damage to the ovaries. The complexity of this procedure requires a surgeon with a high level of skill to ensure successful removal of endometriomas.

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Endometriosis Excision: Experts’ Preferred Treatment

“Many great debates on the surgical management of endometriosis [exist]… there is general consensus that excision is the best for optimal surgical outcome¹.” — Dr. Tammaso Falcone, Chief of Staff & Chief Academic Officer, Cleveland Clinic London; Editor-in-Chief of the Journal of Minimally Invasive Gynecology

Experts agree that surgical excision is the best treatment for endometriosis at all stages. Excision involves cutting out any visible endometriosis laparoscopically through small incisions in the abdomen. When performing excision surgery, surgeons are able to excise the entire endometriosis lesion — including its root — while avoiding any damage to the uterus or other organs in the pelvis. This is especially important for instances of deeply infiltrated endometriosis (DIE) because excision is the only way to completely remove lesions that are deeply embedded in other tissues or organs.

Research² shows excision is much more likely to result in long-term relief. After thorough excision, medical therapy and other nonsurgical methods can be used to better control, but not prevent, any possible progression of the disease.

Find a Highly Skilled Surgeon for Endometriosis Excision

The most important factor in the success of endometriosis excision is a highly skilled surgeon. Surgeons with specialty training in endometriosis are better equipped to handle the intricacies of excision surgery. Because rates of recurrence for endometriosis depend on how thorough the removal was, incomplete excision leads to a much higher chance of recurrence and, in many cases, subsequent surgeries.

It’s crucial to choose a surgeon who has demonstrated expertise in complete laparoscopic endometriosis removal, especially for an initial surgery. Surgeries that are not performed thoroughly the first time often create scar tissue and other adhesions that are left behind, which can cause pain and problems with fertility. When going in for an initial surgery, find a surgeon who will get it right the first time.

In most cases, general OBGYNs have not been trained to perform excision surgery as extensively as is often required. They have an ethical obligation to refer patients to a specialist who can give them the best possible outcome.

At CIGC, our surgeons are fellowship- and oncology-trained. The techniques a GYN oncologist uses to treat disease that involves organs such as the bladder and the bowel are the same techniques our expert surgeons use to excise endometriosis lesions in those same organs. Using high quality optics, CIGC surgeons can identify even the most subtle presentations of disease and remove it completely.

Our surgeons go in with only two small incisions to ensure “barely there” scarring and a quick recovery so patients can get back to their life without pain as soon as possible. CIGC specialists have successfully performed thousands of minimally invasive endometriosis excision surgeries, making them true experts in these highly effective techniques.

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CIGC is dedicated to providing information and materials for women to help navigate the complicated health care system. The CIGC founders, minimally invasive GYN surgical specialists Paul MacKoul, MD, and Natalya Danilyants, MD, developed their advanced GYN surgical techniques using only two small incisions with patients’ well-being in mind.

Their personalized approach to care helps patients gain a better understanding of their condition and the recommended treatment so they can have confidence from the very start. Our surgeons have performed more than 25,000 GYN procedures and are constantly striving to improve outcomes for patients.

References:

  1. Falcone T, Wilson JR. Surgical management of endometriosis: excision or ablation. J Minim Invasive Gynecol. 2014 Nov-Dec;21(6):969.
  2. Yeung P Jr. The laparoscopic management of endometriosis in patients with pelvic pain.  Obstet Gynecol Clin North Am. 2014 Sep;41(3):371-83.

About the Author

Louise van der Does, PhD

Louise van der Does, Ph.D.

As the Vice President of Research at The Center for Innovative GYN Care, Louise van der Does, Ph.D., oversees quantitative and qualitative research efforts for one of the only surgical practices in the United States with an in-house research team. She has published numerous articles on laparoscopic GYN surgery and value-based care that highlight the low complication rates of CIGC’s techniques in peer-reviewed journals. She frequently presents CIGC’s research to top GYN organizations at conferences around the world.