Should laser vaporisation and electro-coagulation of endometriosis be banned?

Andrew Prentice, MD: “Hello I’m Andrew Prentice. I’m a senior lecturer at the University of Cambridge and I have an interest in endometriosis. I’m talking this afternoon with David Redwine from, Bend, Oregon. David’s speaking this week at the COGI conference in Berlin and he is presenting some data, which gives fairly strong views on the subject of the management of the disease. Would you like to comment on that David?”

David Redwine, MD: “Well, I think the title says a lot of it. The title says “Should laser vaporisation and electro-coagulation of endometriosis be banned?” and I’ll be listing 13 reasons for people to consider not using them. 

When you think that laser has been out for about a quarter of a century and yet we still don’t have a follow up study of patients, who have been re-evaluated by repeat surgery in a systematic fashion to gauge how effectively laser destroys endometriosis, and the same thing could be said about electro-coagulation, we’re left with this vacuum of not knowing whether or not laser eradicates endometriosis because the people who use it apparently don’t care enough to ask the questions and do the study to find out whether it eradicates the disease. 

To find out if it works you have to do surgery number one, gauge how much disease there is and then do surgery number two at some time later and see if the disease is there or not. So that’s one of the many failings of laser, that the people who use it and who study about it, aren’t evaluating whether it’s effective.”

Andrew Prentice, MD:“They would argue that there are two issues: One is the disease that we see when we laparoscope patients and the second is the illness that the patients present with. And if the patients are cured of their illness; in other words: they are symptom-free. Then it’s somewhat irrelevant whether the disease persists or not.”

David Redwine, MD: “I don’t think that many patients or many surgeons would agree that it’s irrelevant whether a surgery eradicates a disease, or how much disease is reduced by the treatment. I think that should be the first question. 

Infertility and pain are the leading symptoms of endometriosis and yes, you’re correct, a lot of the studies are looking at that and that’s what brings the patient to the doctor, and the symptoms are important, but it’s high time to know what happens to the disease with these methods of treatment, and we don’t know. 

By contrast, we’ve known for many years through re-operation, studies done after laparotomy excision and laparoscopy excision, exactly what happens to endometriosis with excision. There is between a 50%-60% cure rate, and the patients who are not cured have smaller amounts of disease. Where are those studies with respect to laser and electro-coagulation? We’re still waiting after a quarter of a century.”

Andrew Prentice, MD: “It’s obvious when you excise the disease you remove it in its entirety, and some people would argue that if you destroy all the disease you’re effectively removing it entirely. Why should that be worse than excising the disease?”

David Redwine, MD: “Because with laser electrocoagulation there is no positive control over how deeply to burn. The surgeon is simultaneously going to be worried about burning too deeply, to injure underlying vital structures and so it’s impossible, I think, for laser surgeons and electro-coagulation surgeons to successfully walk that tightrope between 'I need to burn deeply enough to destroy all the disease' and 'I don’t want to burn too deeply to injure other organs'. 

Also, they don’t always know what it is they’re treating. Yes, many times the visual identification of endometriosis is accurate, but sometimes they may be treating carbon residue left over from previous treatments. They may be treating fibrosis, they may be treating cancer. So, what is being treated and how completely it was treated becomes two important points that are solely the opinion of the surgeon. There is absolutely no scientific control over these modes of treatment.”

Andrew Prentice, MD: “So you are advocating excision of the disease in much the same way as we’d excise cancer so we can evaluate the extent of disease-free margins?”

David Redwine, MD: “Not necessarily similar to cancer in terms of disease-free margins. But when you understand the morphology of endometriosis, which can sometimes be very spectacular and very invasive and the disease can go several centimetres beneath the visible surface, it just kind of violates common sense to think that shining a light at the surface of the endometriosis or spraying electrons at its surface is going to go down deeply enough to completely destroy the disease. These forms of treatment just don’t make common sense either.”

Andrew Prentice, MD: “Seems a bit like trying to melt ice down to come out of the water but there’s still enough below to sink the Titanic.”

David Redwine, MD: “I’m sure that they were probably shining a light at that iceberg trying to melt it unsuccessfully even in those days. 

Another thing about laser vaporisation and electro-coagulation is that surely a surgeon would not knowingly, if he knew that the disease was this far below the surface, shine a light at it and expect it to be destroyed. And so, one of the illusions that laser vaporisation and electro-coagulation create in the surgeon’s mind is that the surgeon is always treating a fairly superficial disease because no surgeon in his right mind would use those modalities if he knew it went that deep. 

The fact is they can’t tell how deep it is and therefore in the back of their minds they’re thinking: 'I believe this is a superficial disease' and 'I believe this is sufficient treatment for it'. Again, it’s just a matter of opinion. 

Another thing that laser and electro-coagulation do is they reduce the surgeon’s skill because there is no more skill particularly to using laser than shining a flashlight at the side of a barn. It’s a little more sophisticated than that obviously, and there’s a little more to electro-coagulation than putting the metal probe against something and stepping on a foot pedal. 

So if gynaecologists around the world are going to be reduced to surgeons who shine lights at walls and spray electrons at surfaces what about the recto-peritoneal dissections that are necessary, what about protecting normal anatomy, what about repairing the anatomy that has been altered by the surgery necessarily? So these things are eroding surgeons' skills and that’s a big part of our gynaecological heritage to let go of.”

Andrew Prentice, MD: “That said, I take it you wouldn’t be adverse if we were using these energy modalities to excise tissue?”

David Redwine, MD: “No. I have no qualm with that and many people do a very good job with laser excision. Electro-coagulation excision – obviously that would be somewhat of a difficult concept I think surgically. I use electro surgery to excise but it’s not coagulating, it’s kind of a high energy level and a very quick cut so it’s very much like laser excision is. But just treating the surface of these lesions is leaving a lot of disease in. It’s going to continue to increase health care costs because it goes without saying that patients will have to come back for more and more surgeries. 

And then we have another perverse illusion of the disease being treated by these ineffective methods and that is that the doctor sees the patient coming back for surgery and he can tell the patient, ‘Well Mrs. Smith I eradicated all of your disease with a laser by shining a light at it but you see the reason you are back with pain is because of Sampson’s theory of reflux menstruation. The disease always comes back.’ And so surgeons can explain all their failures of therapy, not on the inadequacies of the techniques they are using, but on a theory that still has not been proven. 

It’s like incomplete surgery and Sampson’s theory have an unholy, symbiotic relationship that support each other along the way. The Sampson’s theory problem gets the surgeons off the hook every time.”

Andrew Prentice, MD: “Except for the surgeons who’ve done a hysterectomy and they have recurrent disease because they’ve incompletely removed it. That’s a prime example of active disease left behind".

David Redwine, MD: “And there have been generations of gynaecologists that have been told that if you remove the uterus, tubes and ovaries they’ll make the endometriosis go away. I’ve seen about 200 such patients where it didn’t work. And yes, many times removal of the uterus, tubes and ovaries will relieve a lot of pain, though obviously it will relieve pain due to dysmenorrhoea, fibroids, adenomyosis, ovulation pain, and so on. Idiopathic pelvic pains, sometimes, and a lot of the pain relieved by hysterectomy for endometriosis may be pain that was caused by the organs, not the endometriosis, so the mode of hysterectomy as treatment of endometriosis seems better than it really is because it’s treating other things. 

If the woman is lucky enough not to have much endometriosis pain she’ll judge it a good operation. If she’s unlucky enough with more invasive disease that may have more aromatase conversion into the local oestrogen, she may not feel like it was such a good operation because she was the 5%-10%, who was destined to continue to hurt. It’s never made sense to me to think of treating something surgically by leaving it in and removing something else. It just does not make sense.”

Andrew Prentice, MD: “I would agree with that entirely. There’s no doubt though that it remains a difficult surgical challenge, and perhaps many surgeons use these techniques because they feel safe with them, because they’re actually not prepared to take the risk that the patient actually requires to be taken to alleviate the disease, remove the disease.”

David Redwine, MD: “And that goes back to reducing the surgeon’s skill. They’ll never get better, they’ll never develop skill if they continue shining the light and, again, we’ve had an entire generation or two of gynaecological surgeons that have come along that have had their skill levels reduced and eroded because they have no concept of how to do the surgery and also they have no concept of the invasive nature of the disease, which perpetuates the ignorance and the incomplete treatments.”

Andrew Prentice, MD: “So would you advocate then, if you have difficult disease like that perhaps, that you personally got other gynaecologists involved and they work closely with other specialists, colorectal surgeons, urologists, who may have complementary skills that can be used in these patients?”

David Redwine, MD: “Yes, and there are certain levels of possible treatments that gynaecologists can do. The general gynaecologist, who is also delivering babies, will still have to do that initial laparoscopy but they can do a better job in terms of identifying where the disease is, is the bowel involved? Fine, maybe the patient deserves one trial of laser or electrocoagulation just to see what happens, but then if that first procedure doesn’t work in that doctor’s hand then he should send that patient to a specialist centre where they have a surgeon who is skilled in pelvic dissections, bowel surgery, urological surgery. And, I think that is happening more and more. There are centres of excellence that are springing up, and we’ll need to see more of those as time goes by. And none of the centres of excellence in the world, as you are probably aware, uses laser vaporisation or electrocoagulation as a means of surgical therapy. They all use excision because it is the only thing that makes any sense. 

Andrew Prentice, MD: “Thank you very much David. I think we will have to wait and see how things develop and the results from these centres of excellence both in the United States and in Europe.” 

David Redwine, MD: “Yes.”

Andrew Prentice, MD: “Thank you.”

See also David Redwine's paper on whether laser vaporisation and electrocoagulation of endometriosis should be banned?  

Comment:
Dr.Redwine's "experience" suffers from selection bias. He only sees other people's failures and seldom sees the hundreds of patients safely and effectivelly treated with CO2 Laser resection of the peritoneum. These procedures always depend on the skill of the surgeon. Full thickness vaporization after distending the retroperitoneal space with fluid permits agressive and complete ablation but affords a margin of protection of the the underlying tissues. I agree that warming up the superficial peritoneal surface to the point of protein coagulation rarely is adequate. I disagree that the laser technique should be dismissed. Gynaecologists should be made aware that using the laser requires a carefull agressive approach at full thickness resection and ablation.

Peter Dayton, MD

Response:
I appreciate Dr. Dayton's interest in this interview. The Congress at which this information was presented was titled "Controversies in Gynecology and Obstetrics" and apparently the title was apt. I spoke only against laser vaporization, not laser excision. I would recommend that "excision" not be used synonymously with "ablation", since the former is specific and the latter is generic and could include any surgical treatment of endometriosis. Thus, excision would be unfairly lumped with other less effective forms of surgical treatment.

I agree with Dr. Dayton that laser excision is effective treatment for endometriosis, and I heartily endorse excision of endometriosis with electrosurgery, laser, or by knife, fork and spoon if need be. While superficial lesions may be aquadissected off of underlying vital structures and such lesions may have a chance of being destroyed by laser vaporization, complete desruction does not always occur. Dr. Dayton is absolutely correct that my practice is biased in that I operate on many hundreds of patients who have undergone previous attempts at thermal ablation of endometriosis. This number includes several hundred with previous laser vaporization. Among these, several patients have been seen with previous incomplete laser vaporization of superficial disease, the treatment having been performed by internationally acknowledged experts in laser vaporization. Overlying adhesions or carbon induced by laser vaporization assure me that this represented incompletely treated disease rather than new disease.

Dr. Dayton is also correct that the surgery always depends on the surgeon's skill, although with laser vaporization it also depends on the opinion of the surgeon that the disease has been completely treated. Endometriosis can be incredibly invasive. Just as no one would believe that laser vaporization would completely treat invasive cancer, no one can truly believe that this technique is adequate for all cases of endometriosis, yet many surgeons use this technique exclusively for all cases in their practices. Even experts in laser vaporization can't always seem to destroy superficial disease. Since there has been no systematic followup study of the efficacy of laser vaporization as determined by examination of reoperated patients, we still have no idea how effective this technique is. Those who use the technique have a lot of explaining to do.

David Redwine, MD

Comment:
Dr. Redwine is quite fervent for excision, but his logic cannot be denied. If one uses an eraser on paper against a lead mark, there are always some particles left behind. Ablation on endo works the same. Not to say that microscopic disease may be missed with excision, but the odds of effectiveness are greater. Regarding the laziness of surgeons, I confirm Dr. Redwine's claim by saying I know a fertility doctor who uses ablation because its expedient both for him and the patient: she's given the window of improvement to get pregnant and if endo comes back, oh well, we'll just have to schedule another surgery. For him it's too much work to become adept at excision. Should this guy be performing laparoscopy? I think not; the patient is receiving substandard care. Ablation continues because it's a quick'n'easy profit-center for him and obviously many others who don't want or have to put in the training required to be a proper excision laparoscopist. An informed patient will put ablation where it belongs - in the bin with the leech-bloodletting cures. There are not many excisionists, and there won't be as long as ablation continues. 

Dr. Arielle Whubbus, USA