Mak, J., Leonardi, M., & Condous, G. (2022). 'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis. Reproduction & Fertility, 3(3), C23-C28. https://doi.org/10.1530/RAF-21-0117
Mak J, Leonardi M, Condous G. 'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis. Reprod Fertil. 2022;3(3):C23-C28. doi:10.1530/RAF-21-0117
Mak, Jason, et al. "'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis." Reproduction & Fertility, vol. 3, no. 3, 2022, pp. C23-C28.
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Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
Diagnostic laparoscopy stays a safe endometriosis test, authors argue
A 2022 debate article argues that diagnostic laparoscopy is still the gold standard for diagnosis. The authors are surgeons who also do ultrasound. They call the surgery low risk. Imaging helps plan surgery but has not replaced direct viewing.
Key Findings
Across 57 studies and 9865 participants, a Cochrane review recorded no mortality. The 29,966 laparoscopic surgeries in the largest cohort produced 4.64 complications per 1000.
Among 451 women surveyed, only 10.4% received the diagnosis at the first consultation, and 28.4% reported needing more than 20 consultations.
Pooling 49 studies and 4807 participants, a Cochrane review rated MRI and ultrasound as equivalent. Neither was accurate enough to replace surgery for overall pelvic endometriosis.
Among 48 women with pelvic pain lasting a long time, 98% had pathology that history, examination and imaging before surgery had missed.
Among women who had laparoscopy for unexplained infertility, 60% were found to have endometriosis.
Interpretation
This debate article argues one side of a live clinical disagreement. The authors are gynecology surgeons and sonologists. They draw on surveys, cohorts and reviews to make the case for direct viewing. They describe laparoscopy as strong for most pelvic disease. They also note its limits for vaginal and rectosigmoid endometriosis, where deep disease can hide from view. The authors say some missed cases may reflect operator skill, and they call for more research on this. They also report that a 2022 European (ESHRE) guideline cites three opinion pieces for allowing drug treatment without a diagnostic laparoscopy.
RRM Context
Restorative reproductive medicine puts evaluation before treatment and looks for the underlying cause. A direct look at the pelvis fits that order. The 60% finding in unexplained infertility shows why RRM calls that label undiagnosed. Excision is the surgical standard RRM endorses when disease is found. The paper does not specify a technique.
Our editorial summary of this paper, not the article's abstract.
Abstract
Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.
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