Podcast Transcript: Endometriosis Surgery: Techniques & Lessons Learned

[Dr. Mark Hoffman]
Well, I feel like we should have you on for two or three different episodes, to be honest, but I want to try to focus on endometriosis today just because, again, we could have multiple episodes on that, but you're someone who has seen patients with endometriosis throughout your career. What's changed over that time in what we know or what we think we understand about endometriosis?

[Dr. Tommaso Falcone]
The reason I got into managing endometriosis patients is because when we started to do it by laparoscopy, I'd just finished my fellowship at the time in Canada. We were doing basically diagnostic scopes and some adhesions, maybe. Nobody wanted to do it by laparoscopy because we were basically looking to see how we could do it and it took a long time and as you said, didn't pay and nobody wanted to do it. Therefore, I didn't mind doing it and I don't mind taking a long time. I was a salaried assistant professor for the few years there that was part of the group.

We were surgically removing, and there were pioneers, obviously, in the field, like David Redwine, for example, who passed away, as you know. You may not have agreed with him, but he certainly started to look at the disease in a very different way. I listened to him and I said, "He has something here." If we look at what we had when I started 30 years ago, that was the beginning for me, was surgery and the birth control pill, non-steroidals and a GnRH agonist because Leuprolide was there even then. 30 years later, we have a lot of surgery, the birth control pill, Leuprolide, but now it's true we do have the GnRH antagonists, like relugolix, for example. It is a step forward, but it is not a great leap for mankind, if I can paraphrase someone who did a great thing.

Although it's a pill and it gives more flexibility, the concept is the same and it doesn't treat endo, it just shuts off the hypothalamic-gonadal axis, the uterine-gonadal axis. You're basically blocking in a more flexible way, and a more tolerable way. We do not have any drugs that go specifically either to the fibrotic lesion, which is really the main area of research, for example, now around endometriosis. We don't have anything for that. Therefore, when I started, we were operating and we learned how to do the surgery much better with fewer complications. That is true. The modern MIGS surgeons are better than anybody than when they started. I think they learned, and now we have a very low complication rate. We can do it, the equipment is better. We can actually do the surgery with fewer complications, with more insight, more complete surgery, more understanding of the visibility, the phenotyping of the disease, the fibrosis that occurs with it. We are better surgeons at endometriosis. Far better, but we're still removing disease. The medical therapy, again, we have a progestin, we have a birth control pill, we have non-steroidals, and we block the hypothalamic-pituitary-ovarian axis more efficiently, maybe more tolerance, fewer side effects, but we're still doing the same thing, but we're very good at it now as compared to before.

[Dr. Mark Hoffman]
Now, I was just going to ask with advances in surgical techniques and technology, are we making progress on patient symptoms? Again, like the outcomes, they may have better perioperative outcomes, but are they doing any better from a symptomatic perspective in the long run? Do we have that data?

[Dr. Tommaso Falcone]
We do, but when you look at 7, 10, 15-year data, it's really quite delayed. I reported 10 years ago, my seven-year data. The seven-year data didn't have a crucial thing. We didn't realize at that time that we had to put patients on suppressive medical therapy to prevent recurrence. What happened is the initial concept, we did the surgery, then we put them on for six months, maybe a year. We did the bulking surgery, six months of medical therapy. Then we took them off the medical therapy, waited a year and asked them how they're doing. Well, that's true. That's what they do in oncology. You do bulk, chemo and then see if you live. For us, we realized that was not the right approach. The right approach is to keep them on for as long as they are in reproductive age or pregnant. We learned some nuances there. Then, of course, the most recent data, again, is that there is a big recurrence rate in patients that are not suppressed. We did learn that we have to suppress patients post-op, and that's the standard now, till they want to get pregnant. We also learned a few other things from a fertility point of view. From the fertility point of view, what we learned was that endometriosis is a pro-inflammatory disease, and has a tremendous amount of inflammation. Many other diseases, like inflammatory bowel disease, asthma, cell arthritis. We did learn that when you do in vitro fertilization and you do a fresh embryo transfer, there's still a lot of inflammation. Therefore, the success rates were not as good. What we do know now, the tendency is to do the egg retrieval, freeze the embryos, wait for the IVF patient to recover, put them on suppressive medical therapy, which we usually do for embryo transfers, and then do an embryo transfer, and the pregnancy rates are no different than a woman who does not have endometriosis.

What we learned is that for patients that are interested solely in fertility, we need to suppress the inflammation, which we can do quite well with progesterone. We did learn that. Again, is it innovative? We did learn how to do that better. We did learn that IVF does not make endometriosis worse as people think, but you do have higher complications when you're doing the IVF from the egg retrieval or something of that nature. But it isn't worse than the disease.

[Dr. Amy Park]
Culturally, though, I remember this because I wrote some review articles and chapters with you in 2006 to 2009, that's when I did my fellowship. It was still a debate, like should we be even excising all this endometriosis? Remember, it was just people who would be doing biopsies and then they would turn it in. It was a totally different thing. It was excision versus ablation. That was also a big debate which I think the culture has changed around that.

[Dr. Tommaso Falcone]
Well, I don't know.

[Dr. Amy Park]
Oh, you don't think so? Oh, well, I don't know. I'm around all the mixed people, so I don't know.

[Dr. Tommaso Falcone]
Yes, that's right, you're right. Just to tell you the excision versus ablation story. It's somewhat unimportant. If you have a lesion under the ovary, just imagine the ovary, lift the ovary. You see the lesion. You have a choice. You can burn it or excise it. If you burn it, what do you think is under there? The ureter. You can either, two choices, burn it, and then burn the ureter, or laser the top of it and leave the lesion. You have to excise the lesion. You have no choice. Now, if it's under your sacral ligament, it is true, and where the ureter is, you can probably burn it or excise it, and you get the same results if you can go deep enough.

There's no question, all those studies that they're equivalent were all done in patients with very early stage disease that was away from the ureter or the ovary, which we can talk about in a minute. Excision is mandatory if you want to remove all the disease, if you're near the ureter, and half the time you don't know where it is, or it's near the rectum. What are you going to do? Take your bipolar and burn it right on the right. No, you have to excise it. Therefore, excision and the cochlear review and the systematic analysis all say, "Oh, there's no difference," but within the parameters that you are dealing with early stage disease that is not near very important structures.

Now in the ovary, it is true that if you excise, you have less recurrence. You have probably a higher pregnancy rate. Again, within the parameters of what you have to do, if you have a patient who has an endometrioma, and she has no pain, and if you say, okay, I'm going to do IVF, well, removing that cyst is not going to make any difference in the IVF outcome under most circumstances except those where it's so big, you can't get around it to get to do an egg retrieval. To that patient, you say, removing it is not going to make any difference, keep the cyst. Now, if the patient has pain, then you have to operate. Many times, that patient with the ovarian cyst has endometriosis underneath it, which is probably causing most of the pain, the deep endo.

Then finally, we do know that every time you remove the cyst, that you can cause damage. You have to know, but sometimes you have no choice. You have to know the principles of removing an endometrioma in a way in which you damage the ovary the least, which means minimal use of electrosurgery, using suture to close, maybe hemostatic agents, just the concept that you're just going to remove every cyst.

Then finally, there's something that we use now, and it's called the endometriosis fertility index. Now, this was pioneered by a gynecologist named Adamson, who was in California. If you remove a cyst and the patient's tubes are beautiful and there are no adhesions, then the pregnancy rate will be fine or improved. How about that? If you remove the cyst and the tubes look like a wreck because there's so much scar tissue, and the cul-de-sac is completely frozen, the tubes have no movement, the patient's not going to get pregnant. Therefore, you have to be far more conservative. That's where there's an overlap between the MIGS and the infertility group. If the purpose is to become pregnant, and the pelvis does not look like it will allow a spontaneous pregnancy because the tubes are affected, et cetera, then you have to be much more conservative with managing the ovarian cyst.

The ovarian cyst can be managed by different energy forms. Don't overuse electrosurgery, you can use plasma energy, which is what I use, to oblate perhaps part of it. I think that the experience that we have in excision versus oblation, it's not as clear as that. Then the purists in MIGS, some people say, not only do you have to remove the lesion, but you have to remove the normal peritoneum in case there's a microscopic lesion. Well that’s a fundamental misunderstanding of the evolution of endometriosis? Because if you biopsy the peritoneum in an early stage disease, like stage one, you will find that these implants will go away on their own. In fact, we know this from the trials where people have not treated endometriosis and then re-sculpt them six months later, and we'll find regression of disease in some patients, the early stage, not the advanced stage. To take it back, are we closer to the pathophysiology of endometriosis? Most likely, we're closer, but the unifying theory of endometriosis is not going to appear.

We're looking for those genes that predispose you. It turns out there are multiple genes and probably none that will say, "Oh, you're going to get it for sure," just like many polygenic diseases. If there's an environmental component, there's a component of delayed childbearing, there's a multitude of different things, environmental toxins, anomalies, obviously, if you have an obstructive one. There's not going to be a clear pathway where you can say it's unifying and that we're going to have a tremendous burden of inflammation. It's like almost all infectious diseases. Think about it, some people get influenza and die. Others get influenza, they have a sniveling nose. Why? Host response, et cetera. The unifying theory is not going to be there, which means that right now, therapeutics is still based on a very primitive idea that we have to aim for the clinical manifestation of that disease in the pelvis or elsewhere.

[Dr. Mark Hoffman]
I think that's similar to cancer. I've said this on the show a few times, but we're treating a disease that is at the cellular level or likely the DNA level with steel. I think that ultimately you can't get it all. These surgeons say, "Well, I'm going to take all the peritoneum," but you're not. There's always, first of all, peritoneum left behind, right? You're not taking the peritoneum off the sigmoid. You're not stripping the entire belly, so what are we talking about? Over the uterus, you're not taking the cirrhosis off. There's tons of it left behind. There's always going to be disease left behind. Your pelvis and abdominal cavity are reperitonealizing in what, 24 hours?

Down the road, we can talk about this too if you want, but the idea of what healing and all the changes that occur with that, and the impact on that in terms of chronic pelvic pain or disease progress and those things. As much as we have a better idea of how to manage the effects of the disease, it doesn't seem like we've made a whole lot of progress on managing the disease. It's at least identifying the cause and truly addressing the disease at its nature. All the progress in cancer care is understanding how cancer works. Cutting off more didn't help in certain patients, if it was already spread outside of the initial organ.


[Dr. Tommaso Falcone]
The research though in cancer, for example, like immunotherapy is a big thing now and treatment is becoming less, and less invasive even. Probably in different areas of gynecology, there hasn't been as much investment in research for benign diseases like endometriosis or fibroids. We understand the treatment better, what we should do or not do. Like I said, if a patient says, "I have no pain," we're not going to remove the cyst because we're not treating the pain. If she wants to get pregnant, we can do IVF or she can do spontaneous pregnancy to remove the cyst, but it depends what the pelvis looks like. There is more understanding of the therapeutic benefit of what we have today, but the interventions are the same over the last 25 years. Surgery, as we stated, minimally invasive, fewer side effects, highly skilled, like our MIGS group, that are being trained, I find them amazing. They can do lots of surgery very efficiently, very effectively, and with a low risk in a patient. I just think that we must understand the disease sufficiently as to not over-treat, just like with fibroids and everything else. If you have fibroids and you have no symptoms, even if they're up to your umbilicus, why am I treating it? I'm not curing you, so therefore, I think it's very important to understand that over-treatment causes problems.