Surgical Technique Superficial ovarian lesions can be vaporized. The surgical management of ovarian endometriotic cysts is controversial. The primary indication for extirpation of an endometrioma is to ensure it is not malignant (1). The laparoscopic approach to the management of endometriomata is favored over a laparotomy approach because it offers the advantage of a shorter hospital stay, faster patient recovery, and decreased hospital costs (299). The most common procedures for the treatment of ovarian endometriomas are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. During excision, the ovarian endometrioma is aspirated, followed by incision and removal of the cyst wall from the ovarian cortex with maximal preservation of normal ovarian tissue. During drainage and electrocoagulation, the ovarian endometrioma is aspirated and irrigated, its wall can be inspected with ovarian cystoscopy for intracystic lesions, and it is vaporized to destroy the mucosal lining of the cyst. Small ovarian endometriomata (less than 3-cm diameter) can be treated by drainage and electrocoagulation (1). Ovarian endometriomata larger than 3 cm should be removed completely (1,300). In cases where excision is technically difficult without removing a large part of the ovary, a three-step procedure (marsupialization and rinsing followed by hormonal treatment with GnRH analogues and cyst wall electrocoagulation or laser vaporization 3 months later) should be considered (1,301).
Outcome after Cystectomy Although as little as one-tenth of an ovary may be enough to preserve function and fertility, at least for a while, there is increasing concern that ovarian cystectomy with concomitant removal or destruction of normal ovarian tissue may reduce ovarian follicle reserve and reduce fertility (302). One study reported reduced follicular response in natural and clomiphene citrate– stimulated cycles, but not in gonadotropin-stimulated cycles, in women younger than 35 years of age who underwent cystectomy compared with controls of similar age with normal ovaries (302). According to a systematic review, there is good evidence that excisional surgery for endometriomas with a diameter of 3 cm provides a more favorable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile or had subsequent spontaneous pregnancy (299). This approach should be the favored surgical approach, based on two randomized studies of the laparoscopic management of ovarian endometriomata of greater than 3 cm in size for the primary symptom of pain (303,304). Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of the symptoms of dysmenorrhea (odds ratio [OR] 0.15; 95% CI, 0.06–0.38), dyspareunia (OR 0.08; 95% CI, 0.01–0.51), and nonmenstrual pelvic pain (OR 0.10; 95% CI, 0.02–0.56), a reduced rate of recurrence of the endometrioma (OR 0.41; 95% CI, 0.18–0.93), and with a reduced requirement for further surgery (OR 0.21; 95% CI, 0.05–0.79) than surgery to ablate the endometrioma. For those women subsequently attempting to conceive, it was associated with an increased spontaneous pregnancy rate in women who had documented prior subfertility (OR 5.21; 95% CI, 2.04–13.29).