Management of Ovarian Endometrioma - Nursing Center

482 Alborzi et althe most effective way to treat thesepatients is the surgical method. 30SURGICAL APPROACHBecause medical therapy is not aneffective treatment, endometriomasshould be managed surgically. Surgerynot only improves symptoms for a longerperiod of time, but also increases thepregnancy rate. The main surgical proceduresfor treatment of endometriomainclude, ultrasound-guided or laparoscopy-guidedaspiration, aspiration andsclerotherapy, laparoscopic surgery bymeans of cystectomy or fenestration andcoagulation, radical treatment (ovariectomyor adnexectomy), and treatment bylaparotomy. Randomized studies havedemonstrated that medical therapy beforeor after surgery, including danazolor GnRH-a does not improve the resultsin terms of recurrence of pain orimprovement in infertility outcome. 2ULTRASOUND-GUIDED ASPIRATIONTransvaginal ultrasound-guided drainagewithout surgery does not seem tobe effective. There are at least 5 studiesthat show a high recurrence rate afteraspiration 31–35 (Table 1). Table 1 showsrecurrence rates between 28% and 100%in the 5 different studies.To decrease recurrence rate, somegroups combined aspiration with in situinjection of tetracycline 36,37 ethanol 38 orTABLE 1.AuthorsRecurrence Rate of EndometriomaAfter Ultrasound-guided Aspirationin 5 Different StudiesNo.EndometriomaNo. RecurringEndometriomaAboulgar et al 31 21 6 (28.6%)Giorlandino et al 32 34 18 (53%)Zanetta et al 33 172 168 (97.6%)Troiano and 9 6 (66.6%)Taylor 34Chan et al 35 8 6 (83.3%)methotrexate. 39 Akamatsu et al 38reported reduction of recurrence ofabout 0% to 9% by using ethanol andMesogitis et al 39 observed an 18%recurrence rate after using methotrexate.Fisch and Sher 37 found no recurrenceafter using sclerotherapy with 5% tetracyclineafter 6 weeks of follow up.Another problem that limits the use ofsimple aspiration is its complicationswhich include: infection, abscess formation,and pain. 33,40 Other disadvantagesof this method are inability to rule outany malignancy and the risk of pelvicadhesion after simple aspiration owingto inflammations that occur in responseto endometriotic cyst fluid. 41,42 Theseadhesion formations may cause chronicpelvic pain and infertility. The use ofGnRH-a after aspiration does not showany additional benefit, because reaccumulationof the cyst occurs in theimmediate postaspiration period. 43It can be concluded that simpleaspiration of endometrioma should notbe regarded as first-line treatment but insome situations, such as recurrences andbefore assisted reproductive technology,it could be helpful and act as analternative approach. 37Surgical ModalitiesBecause both laparotomy and laparoscopyhave the same results in termsof pregnancy and recurrence rates,laparoscopy can be considered to be thebest approach for endometriotic cysts;because blood loss during operation, thelength of hospitalization, need for analgesia,and the recovery time of patientsare significantly lower in the laparoscopicgroup. 44–49 Although Joneset al 50 reported that about 42.3% ofendometriomas are operated by laparotomyin the United Kingdom, this isdue to lack of skill and limitation ofsurgical teaching.Recently Chapron et al 51 did a metaanalysisof all available prospective