Current practice for the laparoscopic diagnosis and treatment of endometriosis: a national questionnaire survey of consultant gynaecologists in UK
Mr T. J. Clark, Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, Birmingham, B15 2TG, UK.
Objective To determine current practice regarding laparoscopic diagnosis and treatment of endometriosis.
Design A prospective questionnaire survey.
Setting The United Kingdom.
Population All 1411 UK consultant gynaecologists identified from a Royal College of Obstetricians and Gynaecologists database.
Methods A postal questionnaire was sent to all consultants with reply paid envelopes. A postal reminder was sent three months following the initial questionnaire.
Main outcome measure Current practice for the laparoscopic diagnosis and treatment of endometriosis and willingness to participate in a randomised trial.
Results The response rate was 66% (893/1411). Diagnostic laparoscopy was performed by 87% (772/893) of respondents. Seventy-six percent of these (58/772) were confident to visually diagnose endometriosis and 6% (47/772) routinely verified the diagnosis histologically. Laparoscopic surgery was routinely undertaken by 41% (318/772) of respondents. Ablative therapy was the most frequently employed technique utilised [620/653 (95%)] and electrodiathermy was the most popular energy modality (80%). Among respondents expressing a preference, excision of disease was believed to be more effective, but less safe compared with ablation. One-third of respondents (273/893) were willing to enter patients into a randomised controlled trial to compare laparoscopic treatments for pelvic pain associated with endometriosis.
Conclusion Laparoscopic surgery for endometriosis associated with pelvic pain is routinely undertaken by a large number of UK consultant gynaecologists, but techniques used and beliefs about efficacy vary. In view of this division of opinion regarding the relative roles of laparoscopic treatment methods, a randomised trial comparing the efficacy and safety of these methods is urgently needed.
Pelvic pain remains a common indication for referral to gynaecology clinic: 5% of all new appointments are for chronic pelvic pain.1,2 Diagnostic laparoscopy is usually performed following failure of conservative management and endometriosis accounts for 25% of cases with objective pathology.1 However, there is controversy surrounding the accuracy and reproducibility of visual diagnosis of endometriosis at laparoscopy.3,4 Accurate diagnosis is important to ensure that potentially effective treatment is actually given and to prevent morbidity arising from prescription of inappropriate treatment.5 Furthermore, reproducibility of diagnosis is essential to compare effectiveness of treatments for endometriosis in a robust fashion.
Medical treatment of endometriosis is established,6 but compliance is often limited by side effects and the patient's symptoms may return when treatment is stopped.5–8 Consequently, surgical treatments are becoming increasingly popular6,9,10 in an attempt to provide long term symptom relief, while avoiding chronic use of pharmacological agents. Laparoscopic techniques allow better anatomic visualisation and operative precision compared with open procedures. Laparoscopic ablation of endometriosis has been shown to provide symptom relief in 50% of patients with mild to moderate endometriosis over a six-month period compared with no treatment.10 However, it has been suggested that severity of symptoms is related to depth of infiltration of endometriosis, which is not accounted for in the revised American Fertility Society classification (rAFS). If so, ablation will only superficially treat the lesions, whereas excision may allow complete removal of disease,11 with the likelihood of better long term symptom relief. This, along with safety issues, has generated controversy about the best laparoscopic treatment for endometriosis.
We have conducted a national questionnaire survey of consultant gynaecologists to assess current practice in the diagnosis and treatment of endometriosis in the United Kingdom. We also tried to assess the level of interest in a randomised controlled trial to compare laparoscopic treatment methods.
All consultants on the Membership database of the Royal College of Obstetricians and Gynaecologists (RCOG) were sent a questionnaire. The database is updated on a monthly basis. The aim of the questionnaire was to determine current practice for laparoscopic diagnosis and treatment of endometriosis (Table 1). Consultants who performed diagnostic laparoscopy were requested to provide information regarding their confidence in, and practice of, laparoscopic diagnosis and treatment of endometriosis. If recipients did not perform laparoscopic treatments for endometriosis, then the underlying reasons for this were sought. Those recipients that undertook laparoscopic treatments were asked questions about surgical technique (with particular regard to ablative or excisional approaches) and their views about effectiveness and safety of such techniques. We also asked about membership of endoscopic societies. Recipients were asked if they would be willing to recruit patients into a randomised trial comparing laparoscopic treatments for pelvic pain.
Table 1. Questionnaire: Laparoscopic diagnosis and treatment of endometriosis.
|Do you perform diagnostic laparoscopy?||Yes||No (there is no need to complete the questionnaire, but return)|
|Laparoscopic Diagnosis of Endometriosis|
|1. Are you confident in diagnosing peritoneal lesions as being suggestive of endometriosis?||Always||Mostly||Occasionally||Never|| |
|2. Are you prepared to start treatment for endometriosis based on your visual findings?||Always||Mostly||Occasionally||Never|| |
|3. Do you ever verify your visual diagnosis by performing a peritoneal biopsy?||Routinely||Occasionally||Never|| || |
|Laparoscopic Treatment of Endometriosis|
|4. Do you perform laparoscopic treatment of peritoneal endometriosis?||Routinely||Occasionally||Never|| || |
|5. What technique(s) do you employ for laparoscopic treatment?||Ablation||Excision||Other (please state)|| || |
|6. What energy source(s) to you use?||Laser||Diathermy||Harmonic scalpel||None (mechanical)||Other (please state)|
|7. Regarding the effectiveness of laparoscopic ablation compared with excision for the treatment of pelvic pain, do you believe that:||ablation is more effective||excision is more effective||effectiveness is comparable||neither is effective||don't know|
|8. Regarding the safety of laparoscopic ablation compared with excision, do you believe that:||ablation is safer||excision is safer||safety comparable||neither is safe||don't know|
|9. Would you be interested in recruiting patients in a trial comparing laparoscopic treatments for pelvic pain associated with endometriosis?||Yes||No|| || || |
|10. Please state the reason(s) why you do not perform laparoscopic treatment (Only complete if you answered ‘Never’ to question 4)||Not trained||Do not believe it is effective for relieving pain||Significant potential for surgical morbidity||Insufficient time on operating lists||Other (please state)|
|11. Are you a member of an endoscopic society?||Yes||No|| || || |
In order to maximise the response rate, we designed our survey strategy to incorporate factors known to be associated with improved response rates.12 The questionnaire was brief, relevant and explicit and included a personal cover letter and prepaid response envelope. In addition, a single mailed reminder was sent to non-responders three months after mailing of the original questionnaire.
A total of 1411 consultants were recorded on the database and 893 replies (66%) were received. Seven hundred and seventy-two (87%) of those responding performed diagnostic laparoscopy. Five hundred and eighty-three (76%) were confident in diagnosing peritoneal lesions suggestive of endometriosis and 744 (90%) were prepared to start treatment based on their visual diagnosis in most cases. Histological verification of visual diagnosis was obtained infrequently, with only 47 (6%) routinely performing a peritoneal biopsy and 284 (37%) never undertaking such procedures.
Laparoscopic treatment of endometriosis was performed by 653 consultants (85%) and 318 (49%) did so routinely. Consultant who did not treat laparoscopically cited a lack of training (54%), risk of morbidity arising from surgery (15%) and referral to other colleagues with an interest in endometriosis (15%) as reasons for not doing so.
Laparoscopic thermal ablation was utilised by 620 (95%) and laparoscopic excision was performed by 193 (30%) of consultants who treated laparoscopically. One hundred and sixty consultants (25%) used both modalities.
Five hundred and twenty-two (80%) treating surgeons used diathermy for ablation, 170 (26%) used laser and 72 (11%) used ultrasound (harmonic scalpel). Twenty (3%) performed surgical excision without external energy sources. One hundred and thirty (20%) used more than one energy source.
When asked to comment on effectiveness and safety, half of the 653 respondents performing laparoscopic surgery believed excision to be comparable to ablation. Eighteen percent of those with a preference thought excision was better, and 6% thought ablation was more effective (P= 0.0001). In contrast, ablation was considered to be safer by 37% and excision by 6% (P= 0.0001). A substantial proportion of gynaecologists did not know which technique was better in terms of effectiveness (28%) and safety (17%). Overall, 273 respondents (31%) expressed an interest in recruiting patients for a randomised controlled trial comparing laparoscopic treatments for endometriosis.
There were significant differences in attitude and practice towards laparoscopic treatment between the 190 respondents (21%) affiliated to a specialist endoscopy society and the 582 respondents (79%) who were not affiliated (Table 2).
Table 2. Differences in attitude and practice between members and non-members of specialist endoscopic surgery societies. Numbers are percentages only for clarity.
|‘Always’ confident in visual diagnosis||37||19||1.9 (1.5 to 2.4)|
|Excision more effective than ablation||31||13||2.9 (2.1 to 4.0)|
|Excision safer than ablation||7||4||2.3 (1.2 to 4.1)|
|Willing to recruit to a randomised trial||62||27||2.3 (2.0 to 2.8)|
|Routine biopsy for diagnosis||17||2||7.2 (4.0 to 13.1)|
|Routinely treats laparoscopically||73||31||2.3 (2.0 to 2.7)|
|Excision of disease only||10||3||4.2 (2.1 to 8.0)|
|Excision and ablation of disease||52||14||4.3 (3.5 to 5.4)|
|Ablation alone||38||67||0.5 (0.4 to 0.6)|
|None||3||16||0.25 (0.1 to 0.4)|
This survey provides up-to-date information on the application of laparoscopy for the diagnosis and treatment of endometriosis. It shows that consultant gynaecologists are confident in visually diagnosing endometriosis at laparoscopy and commencing treatment based on this diagnosis. However, such confidence may be misplaced as a recent test accuracy study13 and a systematic review published in this issue14 have shown that endometriosis will be correctly identified in only 50% of cases. There is therefore potential for significant and unnecessary clinical morbidity from unnecessary treatments as a direct consequence of false positive diagnoses. One solution is to perform peritoneal biopsy routinely to provide histological confirmation. At present, only 6% of gynaecologists reported doing this.
Almost half of UK consultant gynaecologists performing diagnostic laparoscopy reported routinely undertaking laparoscopic treatment of peritoneal endometriosis. Ablation using electrodiathermy was by far the most common approach and probability reflects the relative simplicity of the procedure, the cost and availability of the energy source and the available evidence. The only randomised trial assessing effectiveness of laparoscopic surgery in endometriosis in chronic pelvic pain we are aware of showed laser ablation to be effective in alleviating pain compared with placebo.10 Currently, only 25% of UK gynaecologists use laser as the principal energy modality. Moreover, there is controversy regarding the relative efficacy and safety of ablation compared with newer excisional techniques.15,16 Excision techniques have the advantage of providing tissue specimens for histological verification of diagnosis, but generally require a slightly higher level of training and this may explain why such techniques are more prevalent in those affiliated to endoscopic societies.
As is the case with any survey, selection and reporting bias may influence the validity of findings to an unknown degree. For example, respondents may have a greater clinical interest or expertise in laparoscopic surgery for endometriosis and so not be representative of gynaecologists in general. Despite these limitations, we believe that these survey findings should be considered valid and generalisable. Our overall response rate of 66% is close to the desirable 70% response rate where the impact of non-response biases are negligible17 and is equivalent to that obtained in other recent national gynaecological surveys.18,19
Our survey findings demonstrate that there is no consensus regarding which surgical method to employ. In such a state of uncertainty regarding optimal treatment strategies, well-designed and relevant randomised controlled trials are considered necessary.20 Furthermore, patient recruitment is most rapid in this state of equipoise (a technology has been introduced in practice but ideas about its use have not yet become fixed). A randomised controlled trial is therefore required to investigate the therapeutic and cost effectiveness of laparoscopic surgical treatments (ablation vs excision) for the treatment of endometriosis associated with chronic pelvic pain. It is encouraging that one-third of respondents currently performing laparoscopic surgery are willing to enter patients into this trial and interest in such a trial has previously been expressed by laparscopic surgeons in the UK.21 We are currently running a pilot trial to determine the feasibility of a large multicentre study.
The authors would like to thank Wilma Arnold for help with data input and mailing the questionnaire.
TJC generated the concept of the paper, designed the questionnaire and obtained funding. SM administered the survey. TJC analysed the data. SM and TJC wrote the manuscript.
RCOG Endometriosis Millennium Fund (Clark TJ).
Conflicts of Interest