The importance of post
operative treatment of
endometriosis
Relly Y Primariawan
Consultant of Fertility & Endocrinology Reproduction
Consultant of Gynecology Endoscopy
Ob & Gyn Department of Dr.Soetomo Teaching Hospital – School of Medicine of Airlangga Univerisity
INDONESIA
Outline
• INTRODUCTION
• KIND TREATMENT OF ENDOMETRIOSIS
• ENDOMETRIOSIS SURGERY
• WHAT NEXT AFTER SURGERY
• TAKE HOME MESSAGE
Introduction
Endometriosis :
Disease of Theory
Enigma Disease
Bizarre Disease John Sampson MD, 1920s
“Disease of Theory”
Retrograde - Transplantation Theory
Coelomic Metaplasia Theory
Mullerian Remnants Theory
Genetic-Epigentic Theory
ETIOLOGY of Endometriosis
CAUSAL treatment
Symptomatic treatment
(”Tailor” management)
Endometriosis Chronic & Progressive Disease
getting worse & recurrences
Long life management
- Maximizing use medical treatment
- Avoiding repeated surgical procedures
The Practice Committee of the American Society for Reproductive Medicine.
Fertil Steril 2014; 10(4): 927–935
Kind Treatment of Endometriosis
SURGERY (Laparoscopy)
Medical Treatment Infertility Clinic (ART)
What to consider between diagnosis and Treatment?1-3
Diagnosis
Previous Surgery Different forms of
endometriosis
Age Desire of pregnancy
Symptoms
Infertility Clinic Medical Treatmet
Surgical Treatment
1. Leyland N et al. J Obstet Gynaecol Can 2010; 32(7 suppl 2): s1–s32.
2. Dunselman GA et al. Human Reprod 2014; 29(3): 400–412. 3. Streuli I et al. Expert Opin Pharmacoter 2013;14(3): 291–305.
What do the patients expect from Endometriosis Treatment?
• Treat the patient, not the lesion
• Individualize therapy according to needs / choices of patient to:
üOptimise balance of efficacy, safety and tolerability profiles
üEnhance compliance
• Improve QoL
• Allow conception
• Prevent recurrence / progression to chronic pain
• Avoid repeated surgeries
“The ideal treatment should relieve pain,
induce regression of endometriotic lesions, and allow conception”
– Soares SR, et al. Fertil Steril 2012
Vercellini P, et al. Best Pract Res Clin Obstet Gynaecol 2008.
Streuli I et al. Expert Opin Pharmacother 2013. 14(3):291-305.
Soares SR, et al. Fertil Steril 2012; 98(3): 529-55
ONCE ONLY of Surgery in ‘Endometriosis life’
Strategy :
• To decrease number of the unnecessary surgery
• To avoid poorly performed surgeries
• To plan the best moment for surgery
Chapron. SEUD 2018
HOW to avoid unnecessary surgeries of ‘Endometriosis life’
q Medical treatment is first line option for pain (except
desire for pregnancy)
q Post operative (medical) treatment to avoid recurrences
Real recurrences after adequate 1st surgery
q ART as 1st line option for infertility followed by medical treatment
Chapron. SEUD 2018
Endometriosis Surgery
WHICH SURGERY FOR ENDOMETRIOSIS ?
In the past,
symptomatic moderate to severe
endometriosis
most commonly treated by laparotomy
the removal of affected tissue, with or
without hysterectomy and BSO
Recently,
many women with advanced endometriosis have
been treated by a laparosciopic approach
as it results in a shorter hospitalization
and recovery period as compared with
laporotomy
To optimize patient’s outcome and
to minimize exposure to multiple surgeries
at present role of surgery would ideally be reserved for
diagnostic confirmation and simultaneous treatment
SEE & TREAT for Endometriosis Surgery
IMPORTANT ! for optimal surgical management based on a
robust preoperative evaluation
What next after Surgery
Next steps after surgery of endometriosis
No wish pregnancy Still wish pregnancy
Adjuvant Infertility treatment
hormonal (depends on stage,
location and other
treatment
fertility factors)
Recurrence of pain after surgery
After 1 year follow up After 1 year follow up
5-50% 1 10-20% 2
Endometrioma
Deep Endometriosis
Recurrence of lesions after surgery
After 5 year follow up After 5 year follow up
10-30% 1 50% 2
1. Seracchioli et al. Human Reprod 2009; 24(11): 2729–2735.
2. 2. Vercellini et al. Hum Reprod 2009; 24(2): 254–269.
Post-surgical medical therapy for endometriosis can minimize
the recurrence of disease
No post-surgical medical therapy
International guidelines recognize the
importance of post-surgical medical
therapy to minimize recurrence of disease2–4
3 years: 23% recurrence1
5 years: 50% recurrence1
1. Ouchi N et al. J Obstet Gynaecol Res. 2014;40:230–236; 2. Dunselman GA et al (ESHRE). Hum Reprod 2014; 29: 400-412.; 3. SOGC: Leyland N et al. J Obstet
Gynaecol Can. 2010;37:S1–S3;
4. World Endometriosis Society: Johnson N et al. Hum Reprod. 2013;28:1552–1568
Reduce RECURRENCE of Endometriosis
Treatment after
SURGERY (Laparoscopy)
Medical Treatment Infertility Clinic (ART)
The cumulative
probability of
conception in the 222
subjects without other
infertility factors was
about 30% at 18 months
and 50% at 36 months
without significant
differences between
stages
Paolo Vercellini, Edgardo Somigliana, Paola Vigano, Annalisa Abbiati, Giussy Barbara, and Pier Giorgio Crosignani.
Surgery for endometriosis-associated infertility: a pragmatic approach. Human Reproduction, Vol.24, No.2 pp. 254–269, 2009
Nn. R / 28th
Alamat : Gresik - Jatim
Keluhan Utama : Nyeri haid (+)
Nyeri haid dirasakan sebelum operasi th.2016 hingga sekarang
Jk nyeri, hampir setiap bulan mengkonsumi obat anti nyeri & tidak
bisa beraktifitas optimal
Dyschezia mulai dirasakan dalam 1 tahun terakhir, hematochezia (-)
RIWAYAT PERJALANAN SINGKAT
LAPAROTOMI : OPERASi : OPERASJ :
2016 Kista Endometr 2018 Pasang DJ Stent 2019 Lepas DJ Stent
Dextra (ureter) (ureter)
LAPAROTOMI : PA Kista Terdeteksi Hidroneprosis Dilepas DJ stent krn
Endometriosis Dextra Bilateral tetapi KISTA (-) Hidroneprosis membaik.
Penyebab hidroneprosis ??
Inj GnRHa selama 2 bulan
(Post op)
TIDAK mendapatkan terapi
endometriosis dari SpOG2
sebelumnya. Terapi Endo (-)
Selesai injeksi, nyeri lagi tp oleh SpOG yg
USG à kista (-) dikunjungi
22
2021
Konsultasi mandiri (TANPA RUJUKAN)
Setelah keliling dokter tanpa ada yg melakukan terapi endometriosis
Fisik :
KU cukup T= 187/113 N=96 TB=170cm BB=60kg BMI=20,76
Abd : Soepel, mass (-)
RT : Nodul recto-vaginal (+)
RESUME MANAGEMENT PASIEN
29 Mei KUNJUNGAN 1 29 Mei Hasil MRI keluar 6 Juni
OPNAME RS
2021 2021 2021
Deep Endo di corpus posterior Dx.DIE + Hipertensi +
Ax: Nyeri haid (+). T.187/113 Hidroureter Bil + Hidronefrosis
daerah torus uterinus gr.IV Bil + Rwyt Laparotomi
RT.Nodul rectovag(+) (uk.5,8x4,2x4,9cm) yg invasi kistektomi + Rwyt pasang DJ
USG Abd : Ut-sedikit ke anterior wall rectum hgg ke stent ureter
membesar, Kista (-) musculus layer dg kedalaman
1,66cm, sepanjang 4,9cm, Rawat Bersama :
Dx.DIE + Hipertensi + Rwyt Jarak 9cm dari anus disertai - Nefrologist
Laparotomi kistektomi + obliterasi CD - Urologist
Rwyt pasang DJ stent ureter - Digestive Surgeon
Tampak penebalan ligament
sakrouterina ka/ki Planning: Psg DJ stent ureter +
Planning : MRI menyebabkan hidroureter LO (adhesiolisis+eksisi+
ka/ki & hidronefrosis IV ka/ki reseksi usus)
24
Hidronefrosis Gr.IV Bilateral Hidroureter Dextra + Nodul Hidroureter Sinistra
Bladder
Nodul Endo Sakrouteina
Nodul Endo Rekto-Vag Nodul Endo Rekto-Vag
Bilateral
Laboratorium 6 Jun 21 9 Jun 21 11 Jun 21 12 Jun 21 13 Jun 21
Hb 11,1 10,6 12,2
BUN 16 30 18
S.Kreatinin 2,53 2,79 2,27
asi
Kalium 4,6
oper
Natrium 137
SGOT 9,8
SGPT 4,3
GDA 97
Hidroureter Sinistra Hidroureter Dextra
Hidroureter Sinistra Hidroureter Dextra
Eksisi Nodul Endometrios Bladder
Eksisi Nodul Rectovaginal Endometriosis
Deep Endometriosis Rectum
•VAGINA, SAKROUTEINA,
BLADDER & REKTUM
Histopatologi :
didapatkan
ENDOMETRIOSIS EXTERNA
Dalam terapi GnRHa selama 6 x
3,75mg (terakhir injeksi Des 2021)
KONDISI Tidak ada keluhan nyeri lagi
PASIEN Sudah BAK & BAB normal, tidak
SAAT INI nyeri & lancer
T.139/80
• ASRM stated :
‘ Endometriosis should be viewed as a chronic disease
that requires a life-long management plan with the
goal of maximizing the use of medical treatment and
avoiding repeated surgical procedures’
The Practice Committee of the American Society for Reproductive Medicine. Treatment of
pelvic pain associated with endometriosis. Fertil Steril..Vol. 90.Suppl 5.. 2008
§ Medical Treatment is important role to prevent recurrence
after surgery or ART if fertility is not first priority
§ ONCE ONLY of Surgery in ‘Endometriosis life’
§ ‘Tailor’ management for Endometriosis Patients Take Home
§ Treat the patients, NOT the lesion
Message
