Excision vs Ablation for Endometriosis
Author: Nicholas Fogelson, MD
As a practice focused on surgical treatment of endometriosis, we are practitioners of endometriosis excision technique. This technique differs from more traditional ablation type techniques in many ways.
The goal of excision is to remove all endometriotic tissue from the pelvis, or from other areas where it may be. I believe, as do most physicians worldwide who specialize in endometriosis surgical care, that this technique is the optimal way to treat the disease surgically.
Excision differs from ablation techniques in many ways:
Ablation attempts to use heat, electricity, or another energy source to destroy endometriosis implants, while leaving the peritoneum where the implants lie intact. While this technique may have effectiveness for the most superficial of lesions, it is not possible to remove endometriosis lesions of any depth using this technique.
This is a big problem, because many endometriosis lesions are substantially invasive into the tissues they affect, making ablation techniques completely ineffective at completely removing them. It is not unlike an iceberg that floats in the ocean, with 90% of its mass lying beneath the water’s surface. Ablation attempts to remove the iceberg by burning off the bit that lies above the water, which clearly cannot entirely remove the iceberg. Another common metaphor is trying to remove a weed from the garden by cutting the top off, leaving the roots. As anyone knows, such treatment may make the lawn look better for a period of time, but before long the weeds will be back just as before.
Excision, on the other hand, is a technique to dissect underneath the endometriosis lesions all the way down to healthy, non-endometriotic tissue, and then from below, to completely remove the endometriotic tissue. Only by this technique can we have a chance to completely remove endometriosis tissue such that it does not return. While we cannot guarantee that there is never recurrence after excision, we believe excision to have a substantially lower recurrence rate than ablational techniques, particularly for cases of deeply invasive endometroisis.
If endometriosis is being laid down every month, what good does it do to cut it out?
This is the question that is laid down at the feet of excision surgeons by the general OB/GYN world all the time. The problem with the question is that it starts with an incorrect premise, which is that endometriosis is a condition where disease is constantly being deposited in the pelvis and therefore will just come back. There are many theories for the origins of endometriosis (see —-), but the most prominent theory is that endometriosis becomes part of the body very early in fetal development through a process called mulleriosis. This process allows tissues that should have been normal peritoneum to instead take on the cell types of the inside of the uterus. These cells tend to congregate into tracts in the pelvic peritoneum, along the lines of fetal development of the female reproductive organs. The reason this is important is that if endometriosis was only put into the pelvis once, it likely can be removed without high risk of returning. It is for this reason we believe that excision is helpful in the treatment of women with endometriosis.
If I have excision, how likely is the endometriosis to come back?
There are some datasets that suggest that less than 10% of women who have thorough and expert excision of all endometriotic lesions will have endometriosis found at repeat laparoscopy (Redwine et al). My personal experience is that is likely that the real number is somewhat higher than this, probably more like 20-30% of women. Datasets that show a 10% or less recurrence rate ultimately are working with data limited to women that do indeed go on to have a laparoscopy after their original surgery. As such, many women are not captured into this data. Furthermore, data from women who travel to endometriosis centers for surgery may be difficult to accurately capture, and some cases of recurrent disease may go unaccounted for for this reason.
As such, this is an impossible question to answer with 100% accuracy. The only way to definitively answer this question would be to re-operate on every woman that has excision at some time point after her surgery, and look if there is endometriosis that has grown back. Such a study would be unethical, and no one would subject themselves to unnecessary surgery in this way.
What we can clearly say is that at the end of competent endometriosis surgery, we have removed nearly 100% of visible endometriosis, and that in most cases if you go back there is no recurrent or residual disease in the resected areas. We can also say that for deep lesions, ablation techniques have a 0% likelihood of completely removing the lesion.
If excision is so much better, why do most physicians not do it?
Treatment of endometriosis via excision, especially in severe cases, is very much like the way that a cancer surgeon removes disseminated cancer from the pelvis. That is, painstaking dissection with removal of all abnormal tissues. This technique just isn’t taught in general training to become an OB/GYN, because when one is at this level of training one just doesn’t have the surgical skills yet to be able to absorb and replicate advanced excision work. Gynecologic Oncologists are trained in radical excision skills, but in most cases they don’t have a great interest in endometriosis work, and so they rarely develop substantial experience, outside of the ability to a hysterectomy and removal of ovaries in the setting of advanced disease (which is surgically difficult, but not necessarily the optimal surgical treatment for many patients)
So in order to offer excellent excision surgery, you need a physician who both has radical excision skills, and also the interest to put these skills to work in the management of endometriosis. That is a very narrow slice of physicians. I would say there are only a few hundred doctors in the United States that do much excision work at all, and really only a handful who make it their full time work, as I do.
The other barrier to offering excision work is that under the present insurance system, physicians are very poorly rewarded for doing complex endometriosis work. For this reason, very few physicians choose to focus themselves in a field that is technically demanding, requiring years of training and dedication, yet very poorly rewarded. Those that do dedicate themselves often leave the insurance system (as I have) in order to be adequately compensated for their work and expertise.