Ovarian Reserve, Recurrence Rate and Histopathologic Evaluation After DWLS Diode Laser Vaporization of Ovarian Endometriomas: Results From a Prospective, Multicentre, Clinical Trial.

BACKGROUND Endometriosis cyst, or endometrioma (OMA), is one of the most frequent gynaecological pathologies and is commonly associated with symptoms such as infertility and chronic pelvic pain. Randomized and meta-analysis studies demonstrate how the most effective surgery, in terms of percentages of pregnancy after surgery and minor rates of recurrence of cysts or pelvic pain, is the complete removal of the cyst wall through laparoscopic "stripping". However, data has recently emerged on the possible damage determined by "stripping" surgery on the healthy ovarian tissue adjacent to the OMA.

Studies on the anatomopathological characteristics of the wall of the OMA surgically removed have shown that, with the complete removal surgery, part of ovarian tissue is inadvertently removed together with the OMA wall in almost all cases since there is no real cleavage plan between cysts and healthy ovarian tissue. The post-surgery ovarian reserve has been reported, measured as lower levels of antimullerian hormone (AMH), minor values of antral follicular count (AFC), and reduced postoperative ovarian volumes. Worst performances have also been reported for the induction of ovulation for in vitro fertilization techniques. In the event of the removal of bilateral OMA, 2-4% of early premature ovarian failure has been reported, confirming possible surgical damage to healthy ovarian tissue. Following these data, the international scientific community has begun to question the effective superiority of the complete removal approach of the cystic wall, or "stripping", given these new acquisitions on post-surgical ovarian damage. Therefore, the theme of the best therapeutic approach to OMA has become one of the most debated in the gynaecological field. Despite the data on the possible surgical damage, surgical intervention remains one of the cornerstones of OMA therapy.

The recurrence rate evaluation is one of the primary endpoints of all OMA surgery studies. Guo S.w. has estimated a recurrence rate of 21.5% to 2 years and 40-50% to 5 years. In a recent systematic review of Ceccaroni M. et al., 12-30% recurrence rates are shown 2-5 years after surgical treatment.

An alternative technique to "stripping" is the fenestration of the cyst followed by ablation or vaporization with the laser of the internal wall of the cyst left "in situ" without the complete removal of the cystic wall with healthy ovarian tissue. Candiani et al. demonstrated, in their randomized study, that the "One Step" vaporization of the OMA capsule with the CO2 laser is more effective than stripping in reducing the residual follicular damage (in terms of AMH and AFC).

For better results regarding controlled ablation of the cystic wall of the OMA, the DWLS diode laser could be helpful. The combination of two wavelengths, 980 Nm and 1470 Nm, gives a contemporary absorption in H2O and haemoglobin with an excellent ability of hemostasis, cut and vaporization, as previously demonstrated in laparoscopic and hysteroscopic surgery.