António Setúbal, MD - Outsmarting Endo

António Setúbal, MD - Outsmarting Endo

Endometriosis Foundation of America 2014
Outsmarting Endo - António Setúbal
When is hysterectomy indicated for endometriosis?

Good morning everybody, I was asked to just do a quick, a very quick approach when to have or not a hysterectomy when there is endometriosis. This is not my computer but I hope I can manage the situation. It is going to be very short because we have to move on. At the end we are going to have questions and not too many answers. Let me give you a brief history of endometriosis surgery evolution.

It starts that we have the new radicality "the first surgery should be the last". But at the end we start to become more conservative. The reason for that is because we get more and more complications that are not be acceptable for a so-called benign disease like endometriosis. But now, because we have learned a lot, we are coming back to a more radicality of the disease itself. The question is something that even we surgeons when we are doing surgery we cannot answer. We shall not under treat the disease but also we shall not over treat the disease in some cases. The question is what is the cut-off? Sometimes you never know. To give you an example, especially when we talk about the nerves and we talk about the severity of endometriosis into the _____ nerves or into the inferior hypogastric nerves, we cannot see these nerves so we cannot be nerve sparing surgery at all. It is quite difficult and very important because you if you over treat the disease that lady will probably be stuck with us for life because of urinary retention for instance or with sexual problems.

So, again, what is the cut-off? We never know and sometimes when we do surgery the cut-off should be or could be at any time. The question again is when do I have to stop when I am doing surgery and when do I have to continue?

The reasons for more conservative surgery were related to some undesirable complications as I said before; definitive colostomy or permanent urinary retention, ureteral re-implantation complications that are very bad, sexual dysfunction and more, and all of that in young patients. This is not acceptable. The price to pay if you do not do a complete removal of the disease will be a higher risk of recurrence of course, and a high risk of re-operation.

When you talk about the new radicality that I mentioned a couple of slides before it is because we are learning with the disease. We are also gaining higher skills surgeons and a better knowledge of techniques related to ablate completely the disease.

When you talk about this new radicality the question is if it is true for every case? And the answer is not always. Like the example I used earlier concerning the nerves but it could be that you have both ureters stuck into deep endometriosis with complications of the kidneys and so on and so forth.

Severe endometriosis and hysterectomy; you can see in the books total hysterectomy plus BSO is the definitive treatment for severe endometriosis. But I have another question. Should we do this on a regular basis? And of course the answer is no. No because we live in a world where there are a lot of changes. These concern social and cultural things. Women in metropolitan cities like New York or other such cities are young, and with delayed family and professional career planning they still have to keep their fertility for the future. If they have endometriosis at the age of 20 and the doctors say, "Go home, get pregnant" that is not a good answer.

I just published in Fertility and Sterility last month that even in pregnancy you can have very bad complications especially related to bowel perforation. This means the environment of a pregnancy does not protect from the evolution of the disease, at least in some people. But you can read it in the last issue of F&S. As I said yesterday about adenomyosis, be aware that even endometriosis, DIE itself, is becoming more aggressive, as we can see here and as we saw last night even in young patients.

For treatment you have to choose a balance of what to do, and as Professor Mettler already said, about medical treatment. Juan spoke about surgical treatment and because Lone said that I had to be brief, we have to go into different types of combined therapy. Again I stress that pregnancy is probably, definitely, not something that will protect against the progression of disease in some women, you have to move right away. Hysterectomy in young 25-year-old women is something that is not really permissible these days.

When to do hysterectomy in severe patients? Well, if the patient desires it; if family planning is complete; if incapacitating symptoms persist after surgical or combined with medical therapy and usually if the patient comes to us and says, "Look doctor, it's too much and too many years of suffering I just want to get rid of everything" and also fear of progression of the disease. We have talked about progression of the disease, bowel perforation, kidney failure and yesterday and this morning we talked about cancer. And you as patients read about it on the internet - the sites and the blogs and then come to us with fear of progression of disease, which is in evidence. The surgical limits for resection of the disease and the surgical indications are a decision that we, as surgeons, had to take. It is again in the balance between do not under treat but do not over-treat.

Thank you very much.