Endometriose: Prevenção da recidiva; Uso de análogos. Prof. Dr Endometriose: Prevenção da recidiva; Uso de análogos Prof. Dr. Carlos Alberto Petta

Recidiva ou doença residual?

Recidiva ou doença residual?

Follow-up after endometrioma excision in 366 patients michele.vignali@unimi.it Follow-up after endometrioma excision in 366 patients Pain symptoms recurrence 21.8% Recurrence of clinical/US signs 11.6% Reoperation for endometriosis 8.2% OBJECTIVE: Our purpose was to evaluate the recurrence rate after laparoscopic excision of ovarian endometrioma. Study Design: An unrandomized prospective clinical study was performed at 2 tertiary-care centers of 366 patients who had a minimum of 6 months of postoperative follow-up or 6 months after the suspension of medical therapy after laparoscopic ovarian endometrioma excision. Patients underwent clinical examination and vaginal ultrasonography 3, 6, and 12 months after surgery and subsequently at least once a year. We evaluated the cumulative recurrence rate of pain and clinical findings of ovarian endometrioma, the rate of repeated surgery, and the recovery of fertility. RESULTS: During follow-up we observed ultrasonographic recurrence in 26 (7.1%) cases; surgery was repeated in 12 (3.3%) cases. The cumulative rate of ultrasonographic recurrence over 48 months was 11.7%, whereas the cumulative rate of a second surgery was 8.2%. Ultrasonographic cyst recurrence was associated with pain recurrence in 73% of cases, whereas in the remaining 27% the recurrence was asymptomatic. Significant factors related to recurrence of endometriomas would appear to be the stage of disease (P =.03) and previous surgery for endometriosis (P =.003). Eighty-five (23.2%) women conceived during follow-up. CONCLUSIONS: Laparoscopic treatment of endometriomas seems to be both effective and reliable. The rate of recurrence appears to be correlated to the duration of follow-up. Stage IV disease and previous surgery for endometriosis are unfavorable prognostic factors Cumulative rates at 48 months of follow up Busacca M. Am J Obstet Gynecol,1999; 180:519-23

Archives of Gynecology and Obstetrics July 2016, Volume 294, Issue 1, pp 201–207 Can postoperative GnRH agonist treatment prevent endometriosis recurrence? A meta-analysis Qiaomei ZhengHongluan MaoYing XuJing ZhaoXuan WeiPeishu Liu Longer-term (6 months) postoperative administration of GnRH-a can decrease the recurrence risk of endometriosis, whereas 3 months duration of GnRH-a therapy makes no significant difference in preventing the recurrence of endometriosis

Cirurgia apenas não é a resposta Existe a necessidade de terapia adjuvante – Atualmente não existe cura e a cirurgia isoladamente não é a melhor resposta Muitas mulheres (20% to 40%) não tem melhora adequada após cirurgia conservadora1 Cirurgia conservadora é comumente associada a recidiva de sintomas em 5 anos (40-50%) 2 Remoção das lesões pode ser incompleta e depende da habilidade do cirurgião Tratamento cirurgico tem riscos e no caso dos endometriomas tem risco à reserva ovariana2 “Endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures”3 Leyland N, et al. J Obstet Gynaecol Can 2010;32(7 Suppl 2):S1–S32. Guo S-W. Hum. Reprod Update 2009;15(4):441–461. Practice Committee of American Society for Reproductive Medicine. Fertil Steril 2008; 90:S260.

Ovarian stripping of endometriomas, but not of ovarian dermoids, is associated with a significant decrease in residual ovarian volume which may result in diminished ovarian reserve and function. Objective: The aim of this study was to determine whether and to what extent laparoscopic removal of ovarian endometriotic cysts is a tissue-sparing procedure. Study design: At the University Hospital, 77 women of reproductive age with endometriomas and 55 with dermoid cysts underwent laparoscopic removal of the ovarian disease by stripping. Within 1 month before and within 36 months after surgery all patients underwent transvaginal sonographic evaluation of ovarian volume of the endometriomas or dermoid cysts and measurement of the residual ovarian tissue. Results: The residual ovarian volume after surgery was significantly less for the endometrioma group than for the dermoid group. Comparison of the volume of the treated ovary with that of the untreated contralateral ovary showed a significant difference (4.3G2.3 cm3 vs 9.7G3.9 cm3) only in the endometrioma group. Conclusion: Ovarian stripping of endometriomas, but not of ovarian dermoids, is associated with a significant decrease in residual ovarian volume which may result in diminished ovarian reserve and function. Am J Obstet Gynecol 2004;191:68-72

Evidência no uso de terapia médica adjuvante Surgical improvements in endometriosis-associated deep dyspareunia may be rapid but short-term, and recurrence of pain may occur1 Medical treatment may be more gradual, but progressive and sustained1 Variation of Dyspareunia intensity Vercellini P et al. Human Reproduction 2012

Terapia adjuvante reduz chances de recidiva Terapia adjuvante é importante aliado no pós cirúrgico Reduz chances de recidiva de sintomas e doença Principais objetivos do tratamento da endometriose: Reduzir a dor e Prevenir recidiva por mais tempo Volta dos sintomas leva a sofrimento,multiplos tratamentos clínicos e cirurgias repetidas

cpetta@me.com www.drpetta.com.br