Page 338 - Read Online

Page 10 of 15 Tanos et al. Mini-invasive Surg 2020;4:39 I http://dx.doi.org/10.20517/2574-1225.2019.59

throughout adolescence, there is a major opportunity for early diagnosis and treatment at the very initial
stages when focis of 2-3 mm in diameter of endometriosis appear on the ovarian surface, accompanied by
neoangiogenesis and chronic inflammation promoting adhesions, ovarian dysfunction and infertility.

The main concern with regard to endometrioma surgery for adolescents is the high risk of future
recurrence. A retrospective cohort study showed that long-term recurrence of endometriosis is higher
[55]
amongst younger women as compared to older women . Larger cyst size and younger age were reportedly
associated with recurrence in a 2014 retrospective study comparing recurrence rates across subgroups
[56]
of 550 women with endometriomas . In their 2017 study of adolescents with endometrioma who had
[57]
undergone laparoscopic cyst removal via enucleation, Lee et al. found that 16.2% experienced recurrence
after first-line surgery, and that recurrence rates increased proportionally to time since surgery. An attempt
to strip the pseudocapsule to reduce the risk of recurrence will lead to the destruction of a high volume of
healthy ovarian tissue with inadvertent high AMH results and infertility.

Proposal for individualization of management by case identification
Based on the literature, the clinical assessment of endometriomas requires endoscopic establishment of
the diagnosis. High-risk adolescents, in addition to older women seeking fertility treatment, can benefit
from early diagnosis of endometrioma. It is therefore essential that early identification of eligible patients
is improved and standardized, through stepwise clinical reasoning and diagnostic testing as presented in
Figure 2.

Modern ultrasound scanning machines enable accurate diagnosis of endometriomas as small as 1.0 cm,
depending on the knowledge of the operator and BMI of the patient [58,59] . In addition to diagnosing
endometriomas, the myometrial and the sub-endometrial areas should be meticulously examined, as
adenomyosis and adenomyotic cysts may be found; when endometriomas measuring < 3 cm are identified,
we should proceed with TVHL. Bigger endometriomas can progress straight to IVF or be treated with
laparoscopic surgery. Figure 2 outlines options regarding endometrioma management.

Performing standard laparoscopic surgery using 5 mm bipolar instruments on small endometriomas < 5 cm
minimizes the probability of preserving healthy ovarian tissue. Instead, smaller sized endometriomas enable
an “easier” operation to be performed that results in less damage to healthy ovarian tissue, such as, surgery
with 5F bipolar ball or Argon/Plasma jet laser . This also reflects the change to transvaginal surgery as a
[51]
[51]
preferable technique over standard laparoscopy in the case of small endometriomas prior to IVF . Experts
in reproductive surgery increasingly support the ablation method using bipolar techniques, avoiding
[60]
[50]
excessive coagulation and carbonization effect . Carrillo et al. summarized various factors influencing
post-surgery ovarian reserve, one of which was the competence of the surgeon as measured by the ability of
the surgeon to minimize removal of healthy tissue, identify the extent of endometriotic infiltration and the
borders of the lesion, and the ability to minimize coagulation during the procedure. The different treatment
options of endometriomas in adolescents and very young women, according to their clinical characteristics
are presented in Figure 2.

[61]
Recently, Roman et al. proposed using plasma energy ablation as an alternative to cystectomy, finding

first in their pilot studyof eight women that this technique may spare 90% of healthy ovarian parenchyma
that would otherwise be removed during cystectomy. In a subsequent study (30 women with unilateral
endometrioma and no previous surgery), they found a statistically significant reduction in ovarian volume
and antral follicle count (AFC) (P < 0.001) among women who were operated by cystectomy as compared
to those operated on by plasma energy ablation. This association was independent of age, previous
[62]
pregnancy, and endometrioma size .