In a prospective, controlled, randomized, study, surgical therapy with ablation of endometriotic lesions and LUNA was shown to be superior to expectant management 6 months after treatment of mild and moderate endometriosis (295). In women with mild and moderate disease treated with laser, 74% achieved pain relief. Treatment was least effective in women with minimal disease. There were no reported operative or laser complications (295). One year later, symptom relief was still present in 90% of those who responded initially (268,295). Patients with severe disease were not included because surgery resulted in pain relief in 80% of patients who did not respond to medical therapy (295,319). There is randomized evidence that LUNA is not a necessary part of this treatment because addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis stages I to IV did not reduce the medium-or long-term frequency and severity of recurrence of dysmenorrhea (292,293). These data were confirmed in a second randomized trial in women with chronic pelvic pain lasting longer than 6 months without or with minimal endometriosis, adhesions, or pelvic inﬂammatory disease, where LUNA did not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life compared with laparoscopy without pelvic denervation (321).
In a randomized crossover study, laparoscopic excision of endometriosis was found to be more effective than placebo in reducing pain and improving quality of life (294). These results suggest that laparoscopic surgery may be effective for the treatment of pain associated with mild to severe endometriosis. In women with minimal endometriosis, laser treatment may limit progression of disease.
In a systematic review assessing the efficacy of laparoscopic surgery in the treatment of pelvic pain associated with endometriosis and including five randomized controlled studies, meta-analysis demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only at 6 months (OR 5.72; 95%CI, 3.09–10.60; 171 participants, three trials) and 12 months (OR 7.72; 95%CI, 2.97–20.06; 33 participants, one trial) after surgery (291). Few women diagnosed with severe endometriosis were included in the meta-analysis and any conclusions from this meta-analysis regarding treatment of severe endometriosis should be made with caution. It was not possible to draw conclusions from the meta-analysis which specific laparoscopic surgical intervention is most effective (291).
The extent and duration of the therapeutic benefit of surgery for endometriosis-related pain are poorly defined, and the expected benefit is operator dependent (322). In a systematic review based on three randomized controlled studies, the absolute benefit increase of destruction of lesions compared with diagnostic only operation in terms of proportion of women reporting pain relief was between 30% and 40% after short follow-up periods (322). The pain relief ended to decrease with time, and the reoperation rate, based on long-term follow-up studies, was as high as 50% (322). In most case series on excisional surgery for rectovaginal endometriosis, substantial short-term pain relief was experienced by approximately 70% to 80% of the patients who continued the study. At 1-year follow-up, approximately 50% of the women needed analgesics or hormonal treatments (322). Medium-term recurrence of lesions was observed in approximately 20% of the cases, and approximately 25% of the women underwent repetitive surgery (322). It appears that pain recurrence and reoperation rates after conservative surgery for symptomatic endometriosis are high and probably underestimated (322).