Obstetrics and Gynecology Clinics
Volume 26 • Number 1 • March 1999
Copyright © 1999 W. B. Saunders Company
Ana
A. Murphy MD
Department
of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta,
Georgia
Address reprint requests to
Arlene J. Morales, MD
Department of Obstetrics and Gynecology
Emory University School of Medicine
1639 Pierce Drive, Room 4217C
Atlanta, GA 30322
Treatment of endometriosis is the single most frequent indication
for operative laparoscopy in the United States. [21] Estimates of the incidence
of endometriosis vary, ranging from 1% to 2% of
classic implants in asymptomatic fertile women to histologically proven endometriosis in 45% of asymptomatic women. [22] Laparoscopy has enhanced
the ability of the gynecologist to diagnose endometriosis.
With the advent of improved laparoscopic instrumentation and multiple puncture
sites (Fig. 1 (Figure Not Available) A), there is a large overlap in
surgical procedures performed either by laparoscopy or laparotomy. The
principles are similar regardless of the approach, except for the laparoscope's
advantage of magnification, which is particularly helpful in ablating endometriosis. Comparative studies of laparoscopy
versus open laparotomy for gynecologic surgery report shorter hospitalization
stays, reduced costs, and shorter recuperation time with laparoscopy while
maintaining comparable efficacy rates (70% pain relief) in small studies. [3] [16] Additionally, laparoscopy
may decrease the incidence of de novo adhesion formation when compared with
laparotomy. [10]
The surgical
approach to the treatment of endometriosis is
determined largely by the goals of treatment, which must be clearly delineated
prior to surgery. The two major symptoms of endometriosis
are pelvic pain and infertility. The fine balance that exists between reducing
pain and increasing fertility must be carefully considered. If an aggressive
excisional approach is undertaken, excessive adhesions impairing fertility may
ensue. Although most appearances of endometriosis
are recognized by the reproductive surgeon, deeply infiltrating endometriosis may provide an obstacle to the
laparoscopic surgeon.
The findings at
laparoscopy may be described using one of several classification systems. The
most widely accepted system is the revised American Fertility Society (AFS)
classification, which uses a weighted scoring system to arrive at a numerically
assigned stage. Its disadvantages include the lack of
Figure 1. (Figure Not Available) A, Patient
position for operative laparoscopy. Note patient's legs are only slightly above
the plane of the body. Ancillary puncture sites are marked. B, Placement
of instruments in the rectum, vagina, and uterus facilitates identification of
tissue planes and dissection. ( From Helsa JH, Rock JA: Endometriosis. In Rock JA,
Thompson (eds): Telinde's Operative Gynecology, ed 8. Philadelphia,
Lippincott-Raven, 1997, p 603; with permission.)
depth
measurement of the infiltrating lesion and the distribution of peritoneal endometriosis. [1]
Concepts regarding
peritoneal endometriosis have been addressed
since early publications in the 1970s. One can either ablate (vaporize) or
excise superficial implants. Excision of endometrial implants can be
accomplished in areas of loose peritoneum using a CO2 laser beam at 20- to 40-W
superpulse, a knife, a needle electrode at 20- to 40-W unipolar cutting
current, or scissors. The advantage of excision is the ability to obtain a
tissue diagnosis. An incision is made in the surrounding normal peritoneum, its
edge lifted upward, and the lesion undermined using the hydraulic effect of
pressurized irrigant from an aquadissector. The aquadissection allows
separation of the underlying pelvic structures, making cutting away the lesion
easier and safer. In areas such as the uterus and ovary that do not have loose
peritoneum, the endometriotic implants can be directly ablated with laser
energy or electrosurgery.
There is general
consensus that surgery is usually the most effective approach for infertility
associated with moderate or severe endometriosis.
With surgical therapy in this group, 82% of patients with moderate or severe endometriosis become pregnant within 3 years. [2] A meta-analysis of all
trials published in the English literature from 1977 to 1995 as well as an
evidence-based review both concluded that surgical therapy for all stages of endometriosis resulted in improved fecundity. [1] [3]
Marcoux and
co-workers [17] have published the results
of the first multicenter prospective blinded randomized surgical trial
comparing diagnostic versus operative laparoscopic treatment of women with
minimal or mild stages of endometriosis.
Nontreatment follow-up data were obtained at 36 weeks. Of the 172
women
undergoing operative laparoscopy, 50 became pregnant during follow-up compared
with 29 of 169 women who underwent diagnostic laparoscopy. A significant
increase in cycle fecundity from 2.4 to 4.7 per 100 person-months was reported
in the group of women undergoing operative laparoscopy versus those undergoing
diagnostic laparoscopy. Previous to this publication, it was reported that the
crude pregnancy rate for women undergoing laparoscopic treatment of mild
disease (65% to 78%) was similar to rates for women undergoing laparotomy. In
nonprospective nonrandomized trials, monthly fecundity rates ranging from 2.8%
to 6.7% were reported for minimal and mild disease. [18] [19] Monthly fecundity rates
ranging from 3.0% to 5.7% have been reported in women with moderate and severe
stages of endometriosis treated surgically. [6] [19]
It is generally
accepted that surgical therapy for endometriosis
in women with pelvic pain will usually result in a diminution of pain. Because
pain is a symptom with a complex pathophysiologic basis, resolution of pain can
never be guaranteed.
Interest in the
diagnosis and treatment of atypical forms of endometriosis
has increased since its "rediscovery" by Jansen in 1985. Patients
with recurrent or unremitting pelvic pain associated with severe disease
characterized by deep infiltration are being recognized and reassessed. This
type of severe disease is not reflected in the AFS classification, which
classifies severe disease as cystic ovarian disease with extensive adhesions
and not as infiltrative endometriosis. Deep endometriosis can be easily overlooked because it may
not be associated with much visible disease at laparoscopy. Cul-de-sac
obliteration implies the presence of retrocervical deep fibrotic endometriosis.
Interest in
excisional techniques for the resection of endometriosis
has led to the recognition of infiltrating endometriosis
as distinct from peritoneal surface endometriosis.
Koninckx and co-workers [15] studied the frequency of
infiltrating disease and correlated it with revised AFS score, the indication
for therapy (infertility, pain, or both), and the shape of the endometriotic
lesion. The frequency distribution suggested a biphasic pattern with a nadir of
approximately 5 to 6 mm in depth in women with pain, suggesting that endometriosis with an infiltration of deeper than 5 to
6 mm differs from superficial endometriosis.
These lesions also seem to be morphologically different. Cornillie and
co-workers [7] noted mostly
"active" lesions rather than "burnt out" lesions commonly
associated with lesions of intermediate depth. Deep disease is thought to
represent progression of disease because the incidence of typical lesions, deep
lesions, and cystic endometriosis increases with
age. [15] In a minority of women
(approximately 20%), deep infiltrating endometriosis
is the end stage of endometriosis. In the
majority, severe disease is characterized by cystic endometriosis
and adhesive disease as recognized in the revised AFS scoring system.
Deep endometriosis is almost exclusively localized to the
posterior cul-de-sac and the uterosacral ligaments and infrequently to the
uterovesical fold. Koninckx and Martin [13] have described three types
of infiltrating endometriosis. Type I is
characterized by a large pelvic area of typical or subtle lesions surrounded by
white sclerotic tissue. During excision, deeper disease becomes obvious and
grows progressively smaller and deeper (like a cone). Type II endometriosis is formed by retraction of the bowel.
This is recognized clinically as a small typical lesion associated with
retraction. In some women, no lesion is appreciated, but induration is
associated with the retraction. Excision usually
reveals
the nodule. Type III disease is nodular endometriosis
of the rectovaginal septum. These lesions are clinically suspected at the time
of rectovaginal examination when painful nodularities are noted. Occasionally,
they can be seen as small typical lesions at laparoscopy or as dark blue cysts
at the vaginal fornix. This type of disease is most severe and often spreads
laterally to involve the ureter.
Although the
diagnosis of deeply infiltrating endometriosis
may be obvious at clinical examination, vaginal inspection, or laparoscopic
examination, in some women this disease is easily missed. Extremely difficult
to diagnose are small deep endometriotic lesions that are missed at clinical
examination and that are associated with a "clean" or normal pelvis.
Diagnosis may be enhanced if clinical examination is performed during menstruation
in women with chronic pelvic pain, severe dysmenorrhea, or deep dyspareunia. In
most cases, a nodule may be palpated at that time.
Diagnosis of
deep infiltrating disease may be enhanced by obtaining a CA-125 level during
menstruation. [13] Levels above 35 U/mL are
associated with endometriosis with a sensitivity
of 36% and a specificity of 87%. Diagnosis does not seem to be enhanced by
abdominal or vaginal ultrasound examination or MR imaging.
Treatment of
deep infiltrating disease is most commonly surgical because this provides not
only therapy but is instrumental in making the diagnosis. Resection of disease
should follow the tissue planes between normal tissue and the nodule. Lesions
up to 5 to 6 mm in size are generally flat, whereas deep lesions are elongated.
Complete excision may be accomplished laparoscopically in a large number of
cases, but laparotomy, vaginal excision with or without bowel resection, and
reanastomosis may be necessary in others. Whether dissection is accomplished
with a carbon dioxide (CO2 ) laser or sharply is a matter of personal
preference. Many surgeons choose not to use electrosurgery because of the
associated widespread thermal damage and difficulty in recognizing tissue
planes. Excision of deep endometriosis is
technically difficult and requires skill, expertise, and tenacity. Smaller deep
lesions can be excised easily by laparoscopy, whereas larger lesions may need
to be treated at laparotomy. The latter provides better tactile information on
the extent of disease. In most cases, bowel surgery and extensive ureteral
dissections are performed at laparotomy.
When an en bloc
excision is required, attention is first directed to complete dissection of the
anterior rectum throughout the area of involvement until the loose areolar
tissue of the rectovaginal space is reached (Fig. 2) (Figure Not Available) . A
sponge on a ring forceps (to identify the posterior vagina) and a rectal probe
(to delineate the rectum) are essential instruments when performing en bloc
excision (see Fig. 1 (Figure Not Available) B). The rectal serosa is
opened at the junction of the cul-de-sac lesion. With the use of aquadissection,
traction-countertraction, laser, and scissors, careful dissection is continued
until the loose areolar tissue of the rectovaginal space is identified. The
dissection is continued anteriorly to the upper posterior vagina and posterior
cervix. Frequent palpation through rectovaginal examinations helps the surgeon
recognize the appropriate planes.
Because the
diagnosis and extent of disease can be fully appreciated only at the time of
surgery, preoperative examination of the fornix, rectoscopy/sigmoidoscopy, and
intravenous pyelography are highly recommended. Bowel preparation should be
strongly considered in all women suspected of having deep endometriosis because the real extent of disease and
involvement with bowel may be fully appreciated only at the time of surgery.
Pregnancy rates
following excision of deep endometriosis have
not been extensively studied. Nezhat and co-workers [20] reported on a series of
women
Figure 2. (Figure Not Available) Excision of rectovaginal
nodule through a laparoscopic and vaginal approach. A, Palpable deep
nodule of endometriosis in rectovaginal septum, which is visualized vaginally
but not necessarily laparoscopically. B, Laparoscopic dissection of
nodule through posterior cul de sac. C, Vaginal dissection of nodule and
removal through colpotomy incision. D, Closure of rectovaginal septal
defect. ( From Helsa JH, Rock JA: Endometriosis. In Rock JA,
Thompson (eds): Telinde's Operative Gynecology, ed 8. Philadelphia,
Lippincott-Raven, 1997, p 604; with permission.)
referred
because of failure of medical or surgical therapy. Of 61 women with
infertility, 25 achieved pregnancy. Koninckx and Martin [14] examined cumulative
pregnancy rates in 900 women with endometriosis
unassociated with tubal disease and a subfertile partner. Pregnancy rates
seemed to be more correlated with the length of infertility rather than the
extent of disease. The only group with a significantly higher cumulative
pregnancy rate following surgery were women with deep endometriosis
(60% at 1 year). Multivariate analysis revealed that pregnancy was predicted
most strongly by a shorter duration of infertility and by the surgical
treatment of deep or cystic ovarian endometriosis
or both.
Treatment of
pelvic pain can be carried out using both medical and surgical therapy.
Resection of deep endometriosis resulted in
relief of pain in 40% to 60% of women with dyspareunia and dysmenorrhea,
respectively. [5] Nezhat and co-workers [20] noted moderate-to-complete
relief of pain in 162 of 175 women; however, some of these patients had
multiple interventions, thus the results must be interpreted with caution.
Deep endometriosis remains a diagnostic dilemma and a
surgical challenge. A careful history, clinical examination, and laparoscopy
remain the cornerstones
of
diagnosis. The role of CA-125 antigen screening remains to be established.
Treatment depends on the expertise of the surgeon and the extent of disease. If
patients with pelvic pain receive preoperative bowel preparation, appropriate
resection of deep endometriosis can be
undertaken at the time of laparoscopy. Awareness of the clinical signs and
symptoms and the patterns of disease (subtle, classic, superficial, and deep)
and surgical expertise are necessary to treat these patients in the most
appropriate manner.
Both superficial
and deep endometriosis (endometriomas) can occur
on the ovary. Most endometriomas can be excised laparoscopically. Ovarian
endometriomas generally signify advanced-stage disease; therefore, the initial
phase of the surgical procedure should focus on restoring normal relationships
among the fallopian tubes, uterus, and ovaries. Using graspers for elevation
after the ovary is freed from any surrounding adhesions, the surgeon makes an
ellipitical incision over the endometrioma along the axis of the ovary (Fig. 3)
(Figure Not Available) . Once the ovary is mobile, the cyst cavity should be
incised and thoroughly drained with a suction/irrigator device. The plane
between normal ovarian cortex and the endometrioma cyst wall must be
identified. Magnification and a cutting electrosurgical current applied at the
junction (relaxing incision) will help to develop this dissection plane. Once
the plane is identified, grasping forceps are used to stabilize the ovarian
cortex as the cyst wall is removed. Bleeding can be controlled with laser or
bipolar desiccation or fulguration inside the cyst cavity. If the endometrioma
wall is incompletely excised, the remaining cavity should be fulgurated to
destroy any remaining wall to decrease the chance for recurrence. Rarely will
the ovarian cortex need to be reapproximated with sutures. Usually, the ovarian
cortical edges fold over to close the defect, and no suture material is needed.
The findings in
a series of 47 women undergoing laparoscopic laser management for large (3- to
13-cm diameter) endometriomas were reported by Daniell and co-workers. [9] Of the 32 infertile women,
12 (38%) achieved pregnancy after the surgery. Adamson and co-workers [4] reported on 100 infertile
women with surgically managed endometrioma. Forty-eight of these women
underwent laparoscopic treatment, whereas 52 underwent therapy via laparotomy.
Both approaches were efficacious, with minimal complications.
Although
resection of ovarian endometriomas is an effective treatment, aspiration alone
without excision/ablation results in a high (approximately 40%) recurrence
rate. Therefore, this procedure (aspiration of endometrioma) is rarely
indicated.
Bladder
endometriotic implants as large as 5 mm are treated as superficial peritoneal
disease. Lesions larger than 2 cm are frequently associated with deep
muscularis penetration and can require cystectomy and repair if pain is the
presenting symptom.
When endometriosis overlies the ureter, two techniques are
commonly used to minimize damage and aid resection. An aquadissector can be
used to push the ureter away and provide a barrier (Fig. 4) (Figure Not
Available) , or, alternatively, the peritoneum above the ureter can be grasped
and pulled toward the midline while a blunt
Figure 3. (Figure Not Available) Laparoscopic ovarian
cystectomy. A, Ovarian cortex is dissected from the ovary in the area of
rupture usually associated with superficial endometriosis. If possible,
the incision should be made in the most dependent portion of the ovary to
facilitate closure. B, The plane between cyst wall and ovary is
identified and gently hydrodissected, bluntly dissected, or twisted. The ovary
is usually left to heal by secondary intention. C, Large defects may be
approximated by an internal suture. ( From Helsa JH, Rock JA: Endometriosis. In Rock JA,
Thompson (eds): Telinde's Operative Gynecology, ed 8. Philadelphia,
Lippincott-Raven, 1997, p 606; with permission.)
probe
is used to dissect the ureter off the peritoneum. If the peritoneum is adhesed
and the lesion and cannot be dissected, the ureter is most likely involved in the
endometriotic implant, and a ureterocystostomy implantation should be given
careful consideration.
Uterine
suspension is indicated in selected cases of dyspareunia after resection of
posterior cul-de-sac endometriosis. There are several
ways to achieve
Figure 4. (Figure Not Available) Mobilization of ureter
by hydrodissection. The peritoneum is tented and a needle with syringe is used
to elevate the peritoneum. Alternatively, an incision is made and an irrigator
placed in the retroperitoneal space for dissection. ( From Helsa JH, Rock
JA: Endometriosis. In Rock JA, Thompson (eds):
Telinde's Operative Gynecology, ed 8. Philadelphia, Lippincott-Raven, 1997, p
602; with permission.)
uterine
suspension. By means of a technique similar to that used for Falope ring (Cabot
Medical, Langhorne, PA) tubal sterilization, the round ligaments may be
shortened. Placement of multiple Falope rings is necessary to achieve the
proper shortening of the round ligaments. Care should be taken not to lacerate
the broad ligament. Bipolar electrocoagulation should be used for hemostasis.
An alternative
technique is ventrosuspension of the round ligaments. Two 5-mm suprapubic
trocars are inserted, and long Kelly clamps passed through these incisions are
used to grasp the ligament near the midpoint. A knuckle of round ligament is
pulled through the incision in the fascia. With the use of a nonabsorbable
suture, the round ligament is sutured to the rectus fascia. Uterine positioning
is confirmed laparoscopically. In a series of 90 women who underwent
ventrosuspension, 92% noted a reduction in pelvic pain, although no long-term
follow-up is available. [12]
Women undergoing
laparoscopy who present with significant central dysmenorrhea may be considered
candidates for laparoscopic uterosacral nerve ablation (LUNA). LUNA should be
performed only if the uterosacral ligaments are clearly visualized. It can
achieved using a laser or bipolar electrodesiccation and transection/resection
with scissors.
The uterus
should be deviated toward the anterior abdominal wall using an intrauterine manipulator.
The ureters are then identified and atraumatically deviated laterally. The
uterosacral ligaments are traced to their insertion on the
uterus.
After the initial incision is made on the medial aspect of the ligament at its
junction with the uterus, grasping forceps are used on the unroofed ligament
and stretched toward the sidewall to aid in complete transection of the
ligament. A relaxing peritoneal incision can be made to further facilitate
complete transection of the ligament. The relaxing incision should be just
lateral to the uterosacral ligament and medial to the ureter. Bleeding can
usually be managed by bipolar electrodesiccation. Avoidance of the areolar
spaces lateral to the ligament minimizes damage to the ureter and vessels.
Occasionally,
complete uterosacral ligament excision is required if deep endometriosis is present. In this situation, the
relaxing peritoneal incision should be made first and then the ligament bluntly
isolated at its origin and insertion so that excision can occur.
The success of
this procedure is dependent on the completeness of the transection of nerve
fibers along the uterosacral ligament. The reported rate of pain relief in
women with endometriosis is 71%. [11] Although no long-term
studies have been reported, it is generally accepted that the effectiveness of
LUNA may decrease over time.
Women with
central dysmenorrhea, especially those who have previously failed LUNA, may be
candidates for laparoscopic presacral neurectomy (LPSN). Complete
familiarization with retroperitoneal anatomy is essential for any surgeon
performing LPSN. The superior portion of the presacral nerve runs from the
bifurcation of the aorta to the junction of L5-S1 vertebral bodies. The
boundaries for LPSN are (1) superiorly, the bifurcation of the aorta; (2) on
the right, the right internal iliac artery and right ureter; (3) on the left,
the inferior mesenteric and superior hemorrhoidal arteries; (4) inferiorly,
just below the division of the right and left inferior hypogastric plexus; and
(5) deep, the periosteum of the vertebral bodies.
If appropriate,
surgical management of endometriosis is
performed first; the patient is then placed in a left lateral tilt to displace
the bowel from the sacral promontory. The peritoneum overlying the sacral
promontory is grasped and elevated so that a superficial transverse incision is
made over the sacral promontory (body of L5 vertebra) between the inferior
mesenteric artery on the left and the right internal iliac artery, about 1 cm
cephalad to the right ureteral crossing (Fig. 5) (Figure Not Available) .
Mobilization of the presacral tissue can be carried out with either blunt
dissection or bipolar electrodesiccation of laser energy.
The presacral
nerve is isolated by developing the avascular space between the nerve and right
internal iliac artery down to the periosteum. Because the nerve plexus usually
runs slightly to the left of the midline, the next area of dissection should be
far enough out to the left to ensure complete nerve resection without damaging
the inferior mesenteric artery or left ureter. This space similarly should be
dissected down to the periosteum. The left common iliac vein, which can
frequently be noted in the deep connective tissue in this area, is vulnerable
to injury; thus great care is required during dissection. After both right and
left borders have been developed, the nerve is grasped and elevated off the
sacral area. The middle sacral artery and vein are usually adherent to the
periosteum, and injury can be avoided by gentle elevation of the nerve. The
cephalad portion of the nerve is then desiccated and cut. Gentle traction is
applied to the plexus while isolating the inferior border. The inferior aspect
is then elevated, dessicated, and cut. The entire length of removed nerve
plexus
Figure 5. (Figure Not Available) Presacral neurectomy. A,
Anatomic landmarks. B, Dissection begins with identification of the
right ureter and dissection of areolar tissue. C, Dissection reveals the
left internal iliac vessels and superior hemorrhoidal vessels. D,
Dissection is continued to the reflection of left colon. The intervening plexus
is sutured superiorly and inferiorly and excised. E, Completed presacral
neurectomy. ( From Helsa JH, Rock JA: Endometriosis. In Rock JA,
Thompson (eds): Telinde's Operative Gynecology, ed 8. Philadelphia,
Lippincott-Raven, 1997, p 610; with permission.)
should
not exceed 3 to 4 cm. Pathologic examination verifies the presence of the
presacral nerve.
The success rate
of LPSN in relieving pain seems comparable with that reported using laparotomy.
Ninety-one percent of women reported a diminution of pain over a maximum
24-month follow-up. [8]
Currently,
laparoscopy performed with the patient under conscious sedation is usually
limited to diagnostic and relatively simple operative procedures such as lysis
of minimal and mild adhesions and conscious pain mapping for evaluation of
pelvic pain. The use of conscious sedation for diagnostic laparoscopy and tubal
sterilization has been established, and tolerance and efficacy data have
accumulated. Other applications are being developed as the appropriate
instrumentation improves to allow the surgeon increased operative capabilities.
For women with pain and endometriosis, pain
mapping during microlaparoscopy may prove useful in long-term therapy, but it
is too early for any conclusive statement.
Surgical and
medical therapy for endometriosis are not
mutually exclusive, and there is probably a role for combined therapy, although
it is unclear. Preoperative medical therapy holds no role in current surgical
management of endometriosis. Postoperative
medical therapy offers the putative advantage of eliminating residual disease,
although there are no definitive supportive data.
The classic
definition of definitive surgical therapy for endometriosis
is a hysterectomy with bilateral oopherectomy and removal of all endometrial
implants. This definitive surgery is the only known cure for this disease. The
decision to perform these procedures in a young woman is always a difficult
one. The probability that symptoms will persist when hysterectomy (with ovarian
conservation) is performed alone is unknown, and opinions vary widely. If an
oopherectomy is considered, issues of estrogen deprivation in all target
tissues (bone, heart, brain, bladder, central nervous system) should be
addressed before surgery. If the decision to proceed with definitive surgery is
made, a possible approach is laparoscopically assisted vaginal hysterectomy
with bilateral oopherectomy. This surgical technique is discussed elsewhere in
this issue.
It is generally
believed that endometriosis will recur unless
definitive surgery is performed. The time to recurrence is thought to be
dependent on the stage of disease and completeness of initial resection.
Whether most recurrences are true recurrences or progression of incomplete
disease is unknown. In one
case
series, the recurrence rate after complete excision of all visible lesions was
21% at 2 years after surgery. [23] The recurrence rate
reported in the literature ranges from 2% to 47%. [24]
A life-table
analysis of reoperation and persistent recurrent endometriosis
in 359 women after endoscopic treatment revealed that 91 of the women underwent
reoperation within 1 to 10 years after initial surgery. [23] The maximum cumulative rate
of persistent-recurrent disease was 19%, achieved in the fifth postoperative
year. This recurrence rate is lower than the general consensus. Most women do
not undergo repetitive surgery.
Endometriosis is best regarded as a
chronic disease that can vary in symptomatology over time. Endoscopic therapy
for relief of pelvic pain as well as infertility is a therapeutic option. The
formation of a rational treatment plan before surgery will ensure a minimum
number of reproductive surgeries over the patient's lifetime.
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GD, Campbell J, Pasta DJ: Evidence-based practice parameters for the treatment
of endometriosis-associated infertility [presentation].
2. Adamson
GD, Hurd SJ, Pasta DJ, et al: Laparoscopic endometriosis
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3. Adamson
GD, Pasta DJ: Surgical treatment of endometriosis-associated infertility:
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1994
abstract
4. Adamson
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8. Curtis
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9. Daniell
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JR: Laser laparoscopy, a new modality. J Reprod Med 30:413-417, 1985 abstract
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SF: Laparoscopic uterine suspension. J Reprod Med 37:6135-6136, 1992
13. Koninckx
PR, Martin DC: Deep endometriosis: A consequence
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14. Koninckx
PR, Martin DC: Treatment of deeply infiltrating endometriosis.
Curr Opin Gynecol Obstet 6:231-241, 1993
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infiltrating endometriosis is associated with
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AA, Lowney J, Jacobs SL: Endoscopic treatment of endometriosis-associated
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20. Nezhat
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JM: Prevalence of endometriosis in asymptomatic
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DB: Conservative laparoscopic excision of endometriosis
by sharp dissection: Life table analysis of reoperation and persistent or
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