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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Representative Results
  • Discussion
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

Abstract

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.

In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

Introduction

The best surgical treatment for ovarian endometriosis, especially when fertility preservation is a priority for women with a desire for offspring, is still a matter of debate. Although cystectomy is still the recommended technique1, previous studies have raised some concerns about its possible detrimental effect on ovarian reserve and reproductive outcomes due to the inadvertent removal of healthy ovarian parenchyma2,3,4.

Indeed, unlike non-endometriotic cysts, endometrioma is a pseudocyst not surrounded by a real anatomic c....

Protocol

All the studies were conducted in compliance with the Declaration of Helsinki, as outlined in the International Conference on Harmonization Guidelines for Good Clinical Practice. Written informed consent for data collection and anonymous publication of disease-related information is routinely obtained at the institution during patient interviews preceding surgical treatment. Women participating in the randomized controlled study signed a specific informed consent form. The Institutional Review Board of the institution ap.......

Representative Results

The details of the outcomes of the included studies are shown in Table 1.

Ovarian reserve after one-step laser vaporization versus cystectomy in the treatment of ovarian endometrioma13
The aim of this randomized controlled study was to compare the two surgical procedures for endometrioma treatment (cystectomy versus CO2 laser vaporization) in terms of their impact on ovarian reserve markers (AFC and serum AMH concentrat.......

Discussion

The aim of this method is to provide a comprehensive overview of our experience with CO2 fiber laser technology at San Raffaele Scientific Institute since 2015, when the use of this technique first started for the surgical management of endometriomas. Since endometriosis is a chronic benign gynecological condition affecting women of reproductive age with potential offspring desire, surgical techniques need to be as fertility-sparing as possible.

A Cochrane review18.......

Acknowledgements

No external funding was either sought or obtained for this study.

....

Materials

NameCompanyCatalog NumberComments
CO2 fiber laserUltraPulse Duo system, Lumenis LtdAC-1059590
Insufflation NeedleCovidien10065003
Laparoscopic ForcepsErbe Elektromedizin GmbH20195-133
ManipulatorLumenis Ltd
UltraPulse DuoLumenis LtdGA-2000000CO2 laser system
VIO 3Erbe Elektromedizin GmbH10160-000electrosurgical unit
Voluson S8GE Healthcare186958SU5ultrasound scan voluson system 8

References

  1. Bafort, C., Beebeejaun, Y., Tomassetti, C., Bosteels, J., Duffy, J. M. Laparoscopic surgery for endometriosis. The Cochrane Database of Systematic Reviews. 10 (10), (2020).
  2. Somigliana, E., et al.

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