What is endometriosis?

Endometriosis is a chronic debilitating inflammatory condition affecting up to 10 per cent of patients in their reproductive (puberty to menopause) years which equates to approximately over 1.5 million in the UK and 176 million globally.

The disease, where endometrial-like tissue grows outside the uterus, costs approximately £8bn per year to the UK economy in healthcare costs and loss of amenity.

Whilst the classic symptom is pelvic pain of varying intensity, duration and location, it can present with a range of other symptoms and conditions.

Signs and symptoms of endometriosis

• Pain before and/or during periods (dysmenorrhea)
• Pain during or after sex
• Pain on opening bowels
• Pain on passing urine
• More frequent or urgent need to open bowels especially during periods
• More frequent or urgent need to pass urine or waking up many times at night to pass urine
• Blood in stools
• Blood in urine
• Cyclical chest pain and/or cough
• Fatigue
• Infertility > 6 months, especially if any of above is also present

Diagnosis is often delayed by eight to nine years due to lack of awareness by patients and care providers in all settings. Therefore, it is not uncommon for patients to be first diagnosed often fortuitously when undergoing a pelvic USS (ultrasound scan) or MRI (magnetic resonance imaging) when investigating other conditions, for example infertility.

USS is type of scan which uses high-frequency sound waves to create images of internal tissues/organs, whereas MRI uses strong magnetic fields and radio waves to produce such images.

Endometriosis and infertility

Whilst endometriosis is found in up to 50 per cent of patients with infertility, it is usually causative in patients with active disease and/or involvement of the fallopian tubes or ovaries. Whilst medical hormonal therapies are effective, they are not compatible with fertility and therefore many patients with complex endometriosis have to resort to surgery to improve fertility outcomes.

However, surgery carries attendant risks of trauma to bowel and urinary tract (also known as complications), and moreover, patients may experience delays in resuming fertility whilst recovering fully from surgery especially if it is complex.

Laparoscopy and endometriosis

Laparoscopy is a type of surgery which allows a surgeon to use keyhole cuts and a camera for procedures inside the tummy or pelvis.  It is the “gold standard” test for diagnosis and treatment of endometriosis and although invasive in nature is highly safe and effective.

Robotic surgery and endometriosis

Robotic surgery is a type of keyhole surgery undertaken using specialised camera and instruments which are inserted through keyhole cuts but unlike in laparoscopy these are controlled by a surgeon who sits at an ergonomically designed console away from the patient but otherwise in the same theatre.

Robotic surgery has been successfully introduced for routine gynaecological use in selected NHS clinics, for example King’s Fertility, and given its advantages, which include reduced complication rates and blood loss and faster recovery, has revolutionised surgical care of patients including when compared with traditional laparoscopy.

Whilst robotic surgery should be available to all patients, its use is limited by higher costs and limited availability and therefore at present reserved for managing patients with complex surgical and anaesthetic needs.

Another lesser known and heralded advantage of robotic surgery over and above other forms of surgery, including laparoscopy, is the greater ergonomics and intuitiveness it provides which in-turn results in reduced surgeon fatigue especially for complex cases. This in the long-run will improve working life and retention of surgeons at a time of greatest need within the NHS.

The pros of robotic surgery 

• Greater precision
• Superior 3D HD vision
• Minimum tissue trauma
• Nerve sparing
• Lower blood loss and complications
• Less post-operative pain
• Reduced hospital stay
• Quicker recovery
• More ergonomic for the surgeon and reduced surgeon fatigue

The cons of robotic surgery

• Higher capital costs
• Rigorous quality and safety controls
• Only available in select clinics and hospitals

What should women do?

All patients, including adolescents, should familiarise themselves with symptoms and signs of endometriosis and seek a GP appointment accordingly.

Where appropriate, patients should seek a high-quality pelvic USS, but, equally be aware that a negative USS does not rule out endometriosis and therefore, in case of persistent symptoms, seek additional MRI and/or laparoscopy and/or empirical treatments.

Patients with endometriosis should seek referral to a fertility clinic to discuss the nature of their condition and its impact on fertility. Many, but not all, fertility clinics provide high quality pelvic USS during initial diagnostic work-up and therefore benefit from quicker and more accurate diagnosis of endometriosis including deep and/or complex endometriosis.

Women with ovarian endometriosis and even otherwise, should consider preserving fertility by recourse to egg/embryo freezing where applicable.

Patients with severe and/or complex forms of endometriosis should request referral to their local BSGE (British Society of Gynaecological Endoscopy) accredited endometriosis centre.  Where possible they should enquire about availability of robotic surgery in such centres.