title: Comparison between the stripping technique and the combined excisional/ablative technique for the treatment of bilateral ovarian endometriomas: a multicentre RCT.
abstract: OBJECTIVE
  Is the combined excisional/ablative technique for the treatment of ovarian endometriomas better than the traditional stripping technique in terms of recurrence rate?
  
  
  CONCLUSIONS
  There is no evidence that the combined excisional/ablative technique is better than the traditional stripping technique, as similar recurrence rates were observed for the two techniques.
  
  
  BACKGROUND
  The stripping technique is associated with better results compared with ablative, non-excisional techniques for the treatment of ovarian endometriomas. Excisional techniques, such as stripping, have, however, been associated with reduced ovarian reserve as evaluated with anti-Mullerian hormone, and surgical techniques that better preserve the ovarian reserve are needed.
  
  
  METHODS
  A prospective, multicentre, randomized blinded clinical trial was carried out on 51 patients with bilateral endometriomas larger than 3 cm. For each patient, serving as her own control, one ovary was randomized to the stripping technique and the contralateral to the combined excisional/ablative technique. Patients were enrolled between January 2013 and April 2014.
  
  
  METHODS
  Patients of reproductive age with pelvic pain and/or infertility affected by bilateral endometriomas larger than 3 cm were included (n = 51). The patients underwent laparoscopic removal of endometriomas with two different surgical techniques performed at either side after random assignment: complete removal by stripping on one side versus the combined technique, consisting of partial excisional cystectomy followed by completion with ablative surgery using bipolar coagulation, on the other side. Post-operative follow-up was performed at 1, 3 and 6 months after surgery for the evaluation of endometrioma recurrence (primary outcome) and of antral follicle count (AFC) and ovarian volumes (OVs) to assess ovarian reserve (secondary outcome).
  
  
  RESULTS
  Recurrence rates were 5.9% for the stripping technique versus 2.0% for the combined technique (odds ratio 3.00; 95% confidence interval: 0.24-157.5; P = 0.62). AFC in the ovaries treated with the stripping technique did not differ significantly from AFC in ovaries treated with the combined technique at all follow-up visits, whereas OV was significantly lower after the combined technique at the 6-month follow-up visit (P = 0.04).
  
  
  CONCLUSIONS
  A major limitation of this study is the small sample size and particularly for ovarian reserve, the secondary outcome, for which no formal sample size calculation was performed. The lower-than-expected recurrence rates in the present series may be related to the shorter follow-up in our study compared with most studies in the literature. Further studies with larger sample sizes and longer follow-up are needed to confirm the findings of this study. The combined technique using CO2 laser energy instead of bipolar coagulation should also be evaluated.
  
  
  CONCLUSIONS
  The traditional excisional technique, i.e. the stripping technique, should still be considered the gold standard approach for the surgical treatment of endometriomas.
  
  
  BACKGROUND
  No commercial funding was received. The authors report no relevant conflict of interest.
  
  
  BACKGROUND
  ANZCTR number ACTRN12614000653662.
  23 June 2014.
  1 January 2013.
authors.affiliation: Department of Obstetrics and Gynaecology, 'Sapienza' Università di Roma, Rome, Italy ludovico.muzii@uniroma1.it.
authors.forename: Ludovico
authors.initials: L
authors.lastname: Muzii
authors.affiliation: Department of Obstetrics and Gynaecology, 'Sapienza' Università di Roma, Rome, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Achilli
authors.affiliation: Department of Obstetrics and Gynaecology, Università degli Studi di Verona, Verona, Italy.
authors.forename: Valentino
authors.initials: V
authors.lastname: Bergamini
authors.affiliation: Department of Obstetrics and Gynaecology, Università San Raffaele, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Candiani
authors.affiliation: Department of Obstetrics and Gynaecology, Università San Raffaele, Milan, Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Garavaglia
authors.affiliation: Department of Obstetrics and Gynaecology, Università di Siena, Siena, Italy.
authors.forename: Lucia
authors.initials: L
authors.lastname: Lazzeri
authors.affiliation: Department of Obstetrics and Gynaecology, 'Sapienza' Università di Roma, Rome, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Lecce
authors.affiliation: Department of Obstetrics and Gynaecology, Ospedale Civico, Palermo, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Maiorana
authors.affiliation: Department of Obstetrics and Gynaecology, Ospedale Santa Maria Goretti, Latina, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Maneschi
authors.affiliation: Department of Obstetrics and Gynaecology, Università Cattolica del Sacro Cuore di Roma and ISI Paolo VI, Rome, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Marana
authors.affiliation: Department of Obstetrics and Gynaecology, Università degli Studi di Verona, Verona, Italy.
authors.forename: Alessio
authors.initials: A
authors.lastname: Perandini
authors.affiliation: Department of Obstetrics and Gynaecology, 'Sapienza' Università di Roma, Rome, Italy.
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Porpora
authors.affiliation: Department of Obstetrics and Gynaecology, Università di Bologna, Bologna, Italy.
authors.forename: Renato
authors.initials: R
authors.lastname: Seracchioli
authors.affiliation: Department of Obstetrics and Gynaecology, Università di Bologna, Bologna, Italy.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Spagnolo
authors.affiliation: Department of Obstetrics and Gynaecology, Università degli Studi di Milano, Milan, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Vignali
authors.affiliation: Department of Obstetrics and Gynaecology, 'Sapienza' Università di Roma, Rome, Italy.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Benedetti Panici
mesh_terms: D000328:Adult; D004715:Endometriosis / Q000601:surgery*; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D006801:Humans; D006080:Ovarian Follicle / Q000502:physiology; D065851:Ovarian Reserve; D010053:Ovary / Q000601:surgery*; D012008:Recurrence
keywords: antral follicle count; endometrioma; endometriosis; ovarian reserve; ovarian surgery