Fact or Myth? “Laser” is the best way to treat endometriosis

This one is a bit tricky. The answer is “not always”.

Women’s Surgery Group writes:

“It is absolutely critical for the gynecologist to recognize what is and is not endometriosis during laparoscopic surgery. Endo can present as red, clear, white, scarred, black, or any combination of these lesions. Conversely, what looks like endometriosis may be something else. It is necessary for specimens to be obtained for absolute confirmation.

“Some implants are very superficial, others may penetrate one to two inches beneath the surface. Very superficial implants can be successfully destroyed by any number of methods. Deeper implants must be excised to assure that the entire nodule of endometriosis has been removed. Burning the surface of these deep implants with a laser or electrosurgery accomplishes little, leaving the majority of the endometriosis behind.

“The laser is nothing more than a cutting tool, albeit a very accurate one. If the gynecologist is sufficiently skilled and experienced, endometrial implants (both superficial and deep) can be completely removed with lasers, scissors, electrosurgery, or the harmonic scalpel. All work equally well in experienced hands. None have any advantage over the others from the standpoint of postoperative adhesion formation.”

The Center For Endometriosis Care (CEC) writes:

“The surgical approach to endometriosis can be split into four levels: diagnostic, very conservative, aggressive conservative, and radical.

“Diagnostic surgery has diagnosis as its highest priority. That is, the whole point of the operation is to diagnose what’s going on with the patient. No attempt is necessarily made to treat any disease that may be found. We see many patients who believe their prior surgery was a failure when in fact, the surgeon’s desire was to diagnose without treatment. Therefore, the woman may be given a name for her problem (endometriosis) although when her surgery is over she has as much disease as she did beforehand.

“Very conservative surgery is one in which a surgeon might treat very large, obvious, or easily treatable disease. For example, a leaking endometrioma might be drained, or an area of powder-burn implants ablated. Other areas of disease may, by design, be left untreated. Laser ablation, cauterization, and fulguration treat lesions on the surface of the pelvic organs. These techniques are generally discontinued when the visible superficial portion of the endometriosis is no longer recognizable. Unfortunately, this means deeper disease can be left behind to cause more problems. Physicians who believe that endometriosis can never be controlled and will always come back often do this type of surgery.

“Aggressive conservative surgery removes all disease while preserving all organs. The emphasis is on removing all areas of endometriosis and possible endometriosis, while maintaining fertility. Although many surgeons attempt to treat endometriosis using ablative technique, in my opinion this is much less effective than excision.

“Aggressive conservative surgery is performed here at the Center for Endometriosis Care. It is important to remove the disease from the organs, not the organs from the woman.

“Radical surgery describes the removal of the reproductive organs (i.e. uterus, tubes, ovaries). Certainly there are some women who have benefited from this approach, but in my experience the majority of women can attain profound and long-lasting pain relief without resorting to such drastic measures. In addition, there are a host of reports of endometriosis persisting after hysterectomy. Removing a woman’s uterus but leaving implants of endometriosis behind often does not relieve her pain.”

Dr. David Redwine, a notable endometriosis specialist and surgeon, writes:

“Because there is no objective way of knowing how deeply an endometrial lesion might invade by simply looking at it, the laser surgeon may vaporize the surface of a lesion and still leave active disease below. This is particularly true for deeply invasive nodules of the uterosacral ligaments. In addition, the laser surgeon is frequently reluctant to vaporize disease located over the bowel, bladder, ureters, or major vessels for fear of damaging these organs. Again, active disease can remain in the pelvis and continue to cause pain.

“Because laser vaporization completely destroys tissue suspected of being endometriosis, there is no way to confirm through a pathology report that the vaporized tissue was in fact endometriosis, not some other type of abnormal tissue. This can lead to problems in the scientific study of the disease, since the “evidence” presented in a medical journal becomes a matter of opinion rather than a matter of fact.

“No long term studies have been published giving data on pain and recurrent disease after laser vaporization. Studies published to date reflect pregnancy outcome, which is misleading when one is treating pain.

“A surgeon has only two senses that can be used at the operating table: sight and touch. Laser vaporization sacrifices touch entirely and obscures visual cues with carbon residue and smoke. Laser vaporization can leave carbon deposits which can be mistaken later for recurrent disease.

“A laser is an expensive machine and therefore factors into higher healthcare costs. Simpler surgical methods, such as sharp excision, have proven highly effective in eradication of disease and are considerably less expensive. Widely used in the laparotomy era, excision has a long track record of effectiveness in eradicating the disease.

“Use of the laser for endometriosis surgery has not been proven superior to conventional surgery with scissors and blunt dissection, nor has it been proven for any other gynecologic surgery. In fact, one study noted that surgical scissors cause less tissue reaction than carbon dioxide laser when used for cutting.”