Radical Approach and Surgical Menopause – What’s Best for the Patient?

I met a patient during GYN surgery rotation, a 33 years old with stage 4 endometriosis. I watched and assisted her trans-abdominal hysterectomy, bilateral salpingoophorectomy, adhesion lysis and intra-op bilateral ureteral stenting. She had chronic pelvic pain and menorrhagia for years that were refractory to many conservative management such as OCP, progesterone depot shot and D+C. Patient experienced prolonged ileus post-op so she has been a hot topic during our discussion in sign-out (not that she needed it).

Sketch of Radical Abdominal Hysterectomy

Several points about her management were discussed. First and foremost, was trans-abdominal approach the best or could it have been done less invasively via robot. The surgeons who performed her case were concerned about the overabundance of adhesion bands and the extensive resection that was needed, so the invasive approach was chosen. However, a consultant physician who specialize in minimal invasive GYN surgery advocated for the robotic approach when we discussed her post-op status in sign-out. I think there is also a third option of doing a robotic assisted exploratory laparoscopy first, and back out when the adhesions, anatomical distortion, etc pose too much of an obstacle. Of course, you have to be absolutely frank with the patient before the procedure, but this would grant us an opportunity for attempt a much less invasive route with less chance of intra- and post-op complications.

The second dilemma was whether oophorectomy was needed for this 33 years young female. We all know the pathogenesis of endometriosis is estrogen driven, but was removal of both ovaries, creating a surgical menopause, and having the patient be on hormone replacement therapy for 10+ years indicated? From what I found, patient was tired of her dysmenorrhea and had no wish for future childbearing, but I did not think she had a full grasp of predicament of menopause at 33 years old and long duration of hormonal therapy when I talked to her before and after the surgery. Besides, the clinical presentation of endometriosis has absolutely no correlation with severity of lesions grossly (especially when we did not find any ovarian cyst), and less radical approach might have resulted in similar clinical outcome.

I believe I can extrapolate the ethical dilemmas encountered in this case and broaden them to all areas of medicine. It is paramount to go over all treatment options with a patient before reaching a decision. It is also necessary to work towards a goal of patient’s best interest. In this case, perhaps more exploration of treatment alternatives would have changed the course, and perhaps a thorough education about the gravity of early surgical menopause and long term hormonal replacement therapy would have changed her mind and management. I also wonder if more extensive discussion and collaboration among the surgeons would have changed the course of treatment for this woman.