Complications of CO2-laser endoscopic excision of deep endometriosis

The complications during and following endoscopic excision of deep endometriosis were analysed. The data of 225 excisions performed in 212 women had been collected prospectively into a database immediately following surgery and during the follow-up visit. The data confirmed the association of severe pelvic pain and deep endometriosis, severe pelvic being the only indication for surgery in 67, 78 and 76% of women with type I (n = 99), type II (n = 55) and type III (n = 71) lesions respectively. They confirmed that type II and type III were the largest lesions and that they were found predominantly in revised American Fertility Society (AFS) class II. The duration of surgery decreased with expertise (P < 0.01), but increased when deeper or larger lesions were excised (P < 0.0001) and when cystic ovarian endometriosis was also present (P < 0.001). Excision was clinically judged to be complete in 94, 96 and 85% of women with type I, II or III lesions respectively. In order to achieve this, part of the bowel wall had to be resected in 6.3% and part of the posterior vaginal fornix in 13.6% of cases. This risk was associated mainly in type II or III lesions and with larger lesions (P = 0.001). This was not considered as a complication, since all lesions could be repaired endoscopically and since follow-up was uneventful. Complications were one ureter lesion and seven late bowel perforations with periotonitis. Our data did not permit the evaluation as to whether medical pretreatment could improve completeness of surgery or decrease the risk. They revealed, however, that in six of seven women with type III lesions--in whom excision was judged to be complete--no pretreatment had been given and that luteinizing hormone releasing hormone (LHRH) agonist treatment decreased the volume of type II lesions (P = 0.04). In conclusion, complete endoscopic excision could be performed in over 90% of women with deep endometriosis, but required bowel surgery in over 6% of cases. Ureter lesions were rare, but postoperative bowel perforations with periotonitis occurred in 2-3% of cases. Medical pretreatment is advocated since LHRH agonist treatment was shown to shrink the deep endometriotic lesion.