Surgical Management Of Endometriosis Research Articles

Assessing the role of robotic surgery versus laparoscopic surgery in patients with a diagnosis of endometriosis: A meta-analysis.

Surgical management of endometriosis can be carried out with the traditional standard laparoscopic technique or the robotic surgery technique; however, it is not clear if there is a significant difference between techniques. This meta-analysis aims to evaluate and compare the impact of robotic and standard laparoscopic techniques in endometriosis regarding the clinical outcome. Studies comparing robotic surgery to laparoscopic surgery for endometriosis were among the studies from various languages that met the inclusion criteria. Using dichotomous and continuous random-effect models, the results of these investigations (surgery time, hospitalization time, blood loss, complications, and conversion rate) were examined, and the mean difference with 95% confidence intervals was computed. Eight studies from 2013 to 2022 were selected for the current analysis including 1741 patients with endometriosis. The studied data revealed a statistically significant (P = .01) lower operation time related to laparoscopic surgery compared with the robotic technique. In addition, the hospitalization time of laparoscopic surgery is significantly (P = .03) lower than that of robotic surgery. On the other hand, blood loss, rehospitalization, postoperative and intraoperative complications, and conversion rates were not significantly different between both techniques. Heterogeneity values were variable according to the analysis factor, from 0% to 91%. Both robotic and standard laparoscopic techniques have similar outcomes regarding blood loss, rehospitalization, conversion rate, and rate of complication. However, the substantial difference between techniques was in favor of standard laparoscopic surgery regarding operation and hospitalization time.

Perception and Comfort with Endometriosis Management Among OB/GYN Residents.

The diagnosis of endometriosis often takes several years, delaying appropriate care while patients suffer from pelvic pain, dysmenorrhea, and dyspareunia. Understanding whether residents in obstetrics and gynecology (OB/GYN) are being adequately exposed to and trained in the diagnosis and management of the disease is important for improving care. We conducted an online cross-sectional survey of OB/GYN residents to investigate their comfort level and familiarity with endometriosis diagnosis and management. Residency program directors and coordinators of 20 OB/GYN residency programs in California, USA were emailed to disseminate the 31-question, anonymous survey in January to February 2023. Responses were collected using Redcap and analysis was conducted using STATA. 67 residents answered at least one non-demographic question and were included. A resident response rate was not calculated because we were unable to determine how many programs distributed the survey. 84% of residents felt they could recognise symptoms of endometriosis but over 30% of senior residents were not comfortable with sonographic diagnosis of endometrioma. Approximately one third of residents felt comfortable managing hypoestrogenic symptoms, osteoporotic risks, and add-back progestin for certain hormonal therapies. Academic-hospital based residents had significantly more exposure to attendings prescribing long-acting reversible contraception, GnRH antagonists, and GnRH agonists but there were no significant differences in trainee prescribing practices or comfort. More respondents would feel comfortable medically managing endometriosis (52%) than surgically managing the disease (26%) if they were in practice today, with only 39% of PGY3-4 residents feeling comfortable surgically managing endometriosis. There is considerable room for improvement in the education of residents in the diagnosis and medical and surgical management of endometriosis.

Evolving best practices in the surgical management of endometriosis - examining the evidence and expert opinion.

Endometriosis is a common and often debilitating condition, with multiple theories of pathogenesis. Despite the prevalence of endometriosis, the optimal surgical management remains unclear. Laparoscopy is the gold standard for the diagnosis of endometriosis, with biopsy confirmation more accurate than visual diagnosis alone. It is not clear from the existing data whether excision of endometriosis is superior to ablation. Improvement in pain has been documented following peritonectomy, however, controlled trials are lacking. It is not clear whether concomitant hysterectomy improves pain associated with endometriosis, although hysterectomy may reduce reoperation rate. Bilateral oophorectomy performed for the treatment of endometriosis may not be curative without simultaneous excision of all visible lesions, and the risks of surgical menopause should be considered. The rate of appendiceal endometriosis is higher than previously suspected, and may not correlate with intraoperative visual findings, suggesting appendectomy should be considered during surgical treatment of endometriosis. Despite the prevalence of endometriosis, there is a paucity of data to guide optimal surgical management. More high-quality studies are needed.

New technologies in the surgical management of endometriosis

Introduction: Endometriosis is a very common disease that affects up to 10% of the female population. Although medical therapy represents the first-line treatment for endometriosis, it does not always manage to control symptoms. Laparoscopy represents the standard surgical treatment in endometriosis. Robotic-assisted laparoscopy is an innovative mini-invasive surgical technique. Its application in gynecological surgery and in endometriosis has increased in the last decade. Our purpose is to offer an overview of the role of robotic-assisted laparoscopy in the surgical treatment of endometriosis. Methods: We evaluated studies dealing with the new technique in surgery for endometriosis with a focus on robotic surgery. We performed a compressive literature research on PubMed and the Cochrane Library in December 2022. Expert opinion: Robotic-assisted surgery is a feasible and safe approach to endometriosis surgery and is superimposable to laparoscopy in terms of complication rate, blood loss, hospitalization, and long-term improvement of symptoms. The effect of robotic-assisted surgery on operative time is still contradictory and needs to be further investigated. Robotic-assisted laparoscopic surgery can provide particular benefit in the management of women with severe endometriosis secondary to its advantage in surgical precision and ergonomics. Indocyanine green fluorescence angiography could be useful to assist in the vascularization of ureters and bowel anastomosis, to prevent postoperative complication and leakage.

Indocyanine Green–Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff.Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side.Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc.The patient was discharged in one day with reports of minimal pain (Videos 1-3). Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

Is the presence of deep infiltrative endometriosis underestimated in the surgical management of endometriosis?

The aim of the study was to determine the presence of deep infiltrative endometriosis (DIE) in the surgical management of endometriosis. Operation notes and histopathological reports of women with endometriosis were retrospectively analyzed in the Ege University Hospital between 2008 and 2018. A total of 191 women with suspicious of endometriosis but without clinical signs of DIE were enrolled in the study. Laparoscopic diagnosis of DIE was compared with histopathological reports. There was no histopathology before surgery. Endometriosis was suspected only based on symptoms. A total of 213 lesions that were thought to be DIE were removed from 191 women with endometriosis. Among these 213 lesions, 179 specimens were reported as endometriosis and 34 lesions as fibro-adipose tissue. Forty-nine right uterosacral ligaments were excised, and endometriosis was detected in 44 out of 49 specimens. Histopathological examination of 45 left uterosacral ligaments revealed endometriosis in 35 specimens. Finally, 25 endometriotic nodules were removed from the recto-vaginal space, and 22 of these were verified as endometriosis by a pathologist. The positive predictive value of laparoscopic visualization for DIE in the group suspected of endometriosis but without any clinical findings of DIE was 84%. Women with the suspicious of endometriosis, qualified to surgery, because of infertility or pain, should be prudently investigated to confirm or to exclude coexistence of DIE even if no preoperative sign of DIE was observed to provide complete resection. Otherwise, DIE continues to grow, causes pain postoperatively, and complicates subsequent surgery.

8880 Recurrent Endometriosis-Associated Massive Hemorrhagic Ascites: A Case Report and Literature Review

<h3>Study Objective</h3> To discuss the presentation, pathophysiology, and management of large-volume endometriosis-related ascites. <h3>Design</h3> Case report and literature review. <h3>Setting</h3> University-based teaching hospital. <h3>Patients or Participants</h3> A 31-year-old with cyclic pelvic pain presented with new-onset hemorrhagic ascites up to 6L in volume requiring recurrent paracentesis. <h3>Interventions</h3> Initial ultrasound imaging (Figure 1) revealed large volume ascites, normal uterus, and normal ovaries. Computed tomography scan revealed a large amount of ascites with a normal-appearing liver. Paracentesis revealed hemosiderin laden macrophages and no evidence of malignancy or bacterial growth. The patient's medical and hepatologic workup was unremarkable. After undergoing two additional paracentesis procedures, she underwent diagnostic laparoscopy and peritoneal biopsies. Findings included stage 4 endometriosis with posterior cul-de-sac disease, right adnexal and large bowel disease, and diaphragmatic disease (Figure 2). <h3>Measurements and Main Results</h3> The patient was started on high-dose oral progestins postoperatively. Thereafter, she noted symptom improvement and less frequent paracentesis, but stopped therapy due to side effects. She was started on Elagolix and add-back therapy with no recurrence of ascites over one month of follow-up. Large-volume endometriosis-associated ascites is rare, usually recurrent, and thought to be due to massive ovarian transudate plus altered lymphatic drainage¹. Symptoms may mimic those of an ovarian malignancy. Associated CA-125 levels vary and do not correlate with the presence of ascites^2,3. Additionally, 38% of patients present with pleural effusion². Suppressive therapy with gonadotropin-releasing hormone (GnRH) agonists temporarily prevents ascites recurrence, but medical management regimens and outcomes vary^1,3,4. Surgical management of endometriosis without bilateral salpingo-oophorectomy (BSO) is associated with a recurrence rate of over 50%, while BSO is curative¹. <h3>Conclusion</h3> Clinicians should consider endometriosis in the workup for patients presenting with pelvic pain and recurrent large-volume hemorrhagic ascites after ruling out ovarian malignancy. Suppressive therapy with high-dose progestins or GnRH agonists/antagonists may improve symptoms and reduce the risk of recurrent ascites, but rigorous studies are lacking.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

031 Medical and surgical management of endometriosis in teenagers

Menstrual symptoms such as dysmenorrhea are frequently reported, both in adults as in the adolescent population. A significant number of high school students report missed school days due to menstrual symptoms. Endometriosis is associated with painful menstruation and chronic pelvic pain. It’s true prevalence in the adolescent population is unknown, although 2/3rds of laparoscopies performed for pelvic pain in adolescents show endometriosis. Before discussing treatment, it is vital that severe menstrual pain is not regarded as normal, and should warrant further medical advice (which may include ultrasound) in case it has an impact on school and social activities, to reduce diagnostic and treatment delay. Treatment of endometriosis-associated pain may be medical and/or surgical, although data in the adolescent population are scarce. First line medical treatment can be offered with NSAIDs, and where appropriate hormonal treatment such as combined oral contraceptives or progestogens. Although GnRH-analogues have shown to be effective for pain treatment, they should be used very restrictively and with great caution due to their side effects and reduction of (peak) bone mineral density. Surgical treatment can be offered in case of pain not responding to hormonal treatment, or in case large cysts or bowel/ureter obstruction is found. Laparoscopy should be performed by an experienced team, to avoid repeat surgery and its associated risks. Postoperative hormonal treatment is advised to reduce recurrence rates.

Outcomes of laparoscopic management of chronic pelvic pain and endometriosis

This study was designed to determine the rates of reoperation following laparoscopic management of endometriosis, with additional aims to examine long-term fertility and quality of life outcomes. This is a retrospective study and a prospective questionnaire of subjects who underwent laparoscopic surgery for pelvic pain and/or endometriosis from 2010 to 2015. The rate of reoperation was 8.60%. Following surgery, 83.3% of previously infertile subjects with endometriosis attempted to conceive with an 80.0% success rate. Subjects had significant improvement in each quality of life measurement and most sexual function indices analysed. Impact Statement What is already known on this subject? Endometriosis is estimated to affect around 35–50% of women experiencing chronic pelvic pain and/or infertility. Surgical management of endometriosis is recommended for patients who desire fertility, are afflicted by a more severe form of endometriosis, or have had persistent or recurrent pain in spite of medical management. What the results of this study add? The overall rate of reoperation for subjects was low at 8.6%. The majority of infertile patients were able to conceive following surgery. What the implications are of these findings for clinical practice and/or further research? Laparoscopic management of endometriosis is an effective management tool with low rates of reoperation and high efficacy in treating infertility caused by endometriosis.

Value of Minimally Invasive Gynecologic Surgeon in Surgical Management of Endometriosis

The quality of endometriosis surgery performed by a Minimally Invasive Gynecologic Surgeon (MIGS) is significantly different from that of a general gynecologist. Their training offers them the experience to detect subtle endometriosis, excise deeply infiltrative endometriosis, manage extra pelvic endometriosis and restore normal anatomy in stage 4 endometriosis. They are able to preserve fertility in an endometriosis patient if patient desires fertility. They are also able to address or excise endometriosis when performing concurrent hysterectomy, instead of disregarding it.

Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literature

ObjectiveTo highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture.DesignCase series and review of the literature.SettingEndometriosis referral hospitals.Patient(s)Seven young women who underwent laparoscopic resection of DIE, six of whom had uterine rupture before or during labor; the seventh patient had a posterior wall defect that placed her at increased risk of future uterine rupture.Intervention(s)Diagnosis of uterine rupture before or during labor in patients with a history of prior resection of DIE, leading to delivery by emergency delivery section or emergency laparotomy for exploration and repair.Main Outcome Measure(s)Immediate neonate and maternal salvaging caesarean delivery or laparotomy followed by surgical correction of the rupture.Result(s)As of 2019, no publications in the literature had considered uterine rupture among the obstetric complications of endometriosis. The reporting of such findings is crucial because of the increase in surgical management of endometriosis. We report seven cases of uterine rupture in pregnancy in women who had undergone resection of DIE. In six patients, surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient.Conclusion(s)Our case series sheds light on the potential increased risk of uterine rupture during pregnancy among women who have had a prior resection of DIE. In future, if these patients are considered high-risk pregnancy cases, their care should be managed by high-risk obstetric specialists.

Indocyanine green in the surgical management of endometriosis: A systematic review.

Endometriosis is a very common disease that affects up to 10% of the female population. The use of indocyanine green (ICG) dye has been proposed to allow the proper localization of endometriotic lesions during surgery. Our purpose is to offer an overview of near-infrared (NIR)-ICG in the surgical treatment of superficial peritoneal endometriosis and deep infiltrating endometriosis. Electronic databases were searched, including MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, OVID and Cochrane Library. The studies were identified with the use of a mesh combination of the following keywords: "indocyanine green", "endometriosis", "deep endometriosis", "robotic surgery", "laparoscopy", "ureter", "rectosigmoid" from 2000 to May 2020. All articles describing the use of ICG applied to endometriosis surgery were considered for review. Only original papers that reported specific experience data on the topic were included. Moreover, video-articles were included in the analysis. Quality and risk of bias were evaluated by two authors, respectively. Fifty-three studies were reviewed and reviews or comment articles not reporting original data and original articles lacking specific data on the application of ICG in patients affected by endometriosis were excluded. The quality of the 17 studies included was assessed. Eight studies suggested the usefulness of NIR-ICG as a tool in the detection of endometriosis during surgery, and one randomized controlled trial and one prospective study did not confirm the advantage of its use. Eight studies found that NIR-ICG was useful for the evaluation of vascularization in intestinal anastomoses and ureterolysis after surgery for deep infiltrating endometriosis. NIR-ICG appears useful in the evaluation of vascularization in intestinal anastomoses after segmental resection, confirming its role even after ureterolysis for parametrial deep infiltrating endometriosis. However, its usefulness as a tool in the detection of endometriosis during surgery is inconsistent.

Author

The Cochrane database was searched for systematic reviews about endometriosis. The ESHRE guidelines were also included. A search of the British Journal of Obstetrics and Gynaecology “BJOG”, and the Journal of Minimal Invasive Gynaecology “JMIG” individual database for articles about surgical management of endometriosis was done.

Pre-Treatment Imaging in the Surgical Management of Endometriosis

Pre-Treatment Imaging in the Surgical Management of Endometriosis

1218 Excision of Endometriosis: Ureterolysis with Hypogastric Nerve Sparing

Video Objective To identify and highlight preservation of the ureter and hypogastric nerve during excision of superficial endometriosis for the treatment of chronic pelvic pain. Setting This is the case of a 33 y/o G1P1 with history of endometriosis, chronic pelvic pain and dysmenorrhea who failed medical management and is referred for surgical management of endometriosis due to proximity of endometriosis lesions to ureter on a prior diagnostic laparoscopy. Interventions Laparoscopic excision of superficial endometriosis with ureterolysis and skeletonization of the hypogastric nerve. Conclusion The hypogastric nerve and ureter are vital to maintain proper urinary function. These structures can be safely preserved at the time of laparoscopic excision of endometriosis with a proper technique, appreciation and understanding of their anatomic location.

Psychological interventions for endometriosis-related symptoms: a systematic review with narrative data synthesis.

Endometriosis impacts the physical, psychological and quality of life domains of women. Despite the medical and/or surgical management of endometriosis, the presence of persistent pelvic pain and psychological distress often continues, suggesting a role for psychological interventions in treatment planning. The present study aimed to conduct the first systematic review, with narrative data synthesis, on psychological interventions for endometriosis-related symptoms. The study also aimed to determine the effectiveness of current interventions in resolving psychological and pain-related loss of function associated with endometriosis and to identify gaps in the literature requiring further research. A total of 15,816 studies were retrieved through database searching and handsearching, with two researchers identifying 11 full-text studies that met inclusion criteria. Three studies of 'moderate' quality were identified, although the overall quality of studies was found to be 'weak', with a 'high' risk of bias. The findings regarding the effectiveness of psychological interventions for endometriosis-related symptoms remain inconclusive. Further research into psychological interventions for women with endometriosis that employ evidence-based protocols with high intervention integrity is recommended.

The Association Between Hysterectomy and Ovarian Cancer Risk: A Population-Based Record-Linkage Study.

Recent studies have called into question the long-held belief that hysterectomy without oophorectomy protects against ovarian cancer. This population-based longitudinal record-linkage study aimed to explore this relationship, overall and by age at hysterectomy, time period, surgery type, and indication for hysterectomy. We followed the female adult Western Australian population (837 942 women) across a 27-year period using linked electoral, hospital, births, deaths, and cancer records. Surgery dates were determined from hospital records, and ovarian cancer diagnoses (n = 1640) were ascertained from cancer registry records. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between hysterectomy and ovarian cancer incidence. Hysterectomy without oophorectomy (n = 78 594) was not associated with risk of invasive ovarian cancer overall (HR = 0.98, 95% CI = 0.85 to 1.11) or with the most common serous subtype (HR = 1.05, 95% CI = 0.89 to 1.23). Estimates did not vary statistically significantly by age at procedure, time period, or surgical approach. However, among women with endometriosis (5.8%) or with fibroids (5.7%), hysterectomy was associated with substantially decreased ovarian cancer risk overall (HR = 0.17, 95% CI = 0.12 to 0.24, and HR = 0.27, 95% CI = 0.20 to 0.36, respectively) and across all subtypes. Our results suggest that for most women, having a hysterectomy with ovarian conservation is not likely to substantially alter their risk of developing ovarian cancer. However, our results, if confirmed, suggest that ovarian cancer risk reduction could be considered as a possible benefit of hysterectomy when making decisions about surgical management of endometriosis or fibroids.

Surgical Management of Endometriosis- A Mini Review

Surgical Management of Endometriosis- A Mini Review

Surgical Management of Endometriosis in Patients with Chronic Pelvic Pain.

Surgical approaches to endometriosis patients with chronic pelvic pain are multimodal and require individualization. Laparoscopic approaches are preferred over laparotomy when conservatively treating endometriosis via excision or ablation/fulguration of lesions. The available data support cystectomy over fenestration or fulguration for endometriomas; however, there may be associated decreases in ovarian reserve with endometrioma treatment. Presacral neurectomy may be useful in patients with midline pain and LUNA is not effective for the treatment of pelvic pain related to endometriosis. Appendectomy may be considered prophylactically at the time of the surgery for pelvic pain, although more studies are needed. For deep infiltrating endometriosis, the risks of aggressive bowel surgery must be weighed against the benefits of clear pain reduction. Postoperative medical suppressive therapy is strongly recommended to prolong symptom-free intervals of this chronic disease. As definitive therapy, hysterectomy can be helpful especially when combined with endometriosis excision. When performing hysterectomy, bilateral oophorectomy should be given careful consideration, as this procedure leads to premature surgical menopause and may not decrease the possibility of reoperation and persistence of symptoms in patients aged 30 to 39 years with chronic pain.