{"paper_id":"69b8a35d-7f4c-44a2-a8b4-e2d8f20bfcd9","body_text":"Conservative Management versus Rectal\nR e s e c t i o ni nD e e pI nfiltrating Endometriosis of\nthe Rectum\nAhmed K. Eltaher 1 Mohamed Mahmoud Almeniwy 1 Mohamed Adel Saleh 1 Alaa Haggag 1\nAhmed S. Allam 2 Ola A. Harb 3 Walid S. H. Elsayed 4 Amany M. Abdallah 5 Mahmoud Kotb 6\nMustafa Omara 6 Ahmed Metwally Elkattawy 6\n1 Department of General Surgery, Faculty of Medicine, Zagazig\nUniversity Faculty of Human Medicine, Zagazig University, Zagazig,\nEgypt\n2 Department of Internal Medicine, Faculty of Medicine, Zagazig\nUniversity Faculty of Human Medicine, Zagazig University, Zagazig,\nEgypt\n3 Faculty of Human Medicine, Zagazig University, Zagazig, Egypt\n4 Department of Pathology, Faculty of Medicine, Tabuk University\nUniversity| UT: University of Tabuk\nJ Coloproctol 2026;46(1):s00451814452.\nAddress for correspondence Ola A. Harb, Faculty of Human Medicine,\nZagazig University, Zagazig, Egypt (e-mail: olaharb2015@gmail.com).\n5 Department of Family Medicine, Zagazig University Faculty of\nHuman Medicine, Egypt\n6 Department of Gynecology and Obstetrics, Faculty of Medicine,\nZagazig University Faculty of Human Medicine, Zagazig University,\nZagazig, Egypt\nKeywords\n► deep endometriosis\n► conservative\n► rectal resection\nAbstract Background Rectal deep in filtrating endometriosis has become an increasing prob-\nlem with two main management strategies; radical surgery by segmental colorectal\nresection, and a conservative surgery that includes removal of the lesion with rectal\nconservation.\nAim was to compare between conservative management of deep in filtrating endome-\ntriosis of the rectum by shaving or disc excision and segmental radical colorectal\nresection regarding short term patients ’ outcome, digestive and urinary outcomes.\nPatients and methods: Included 60 patients with deep endometriosis in filtrating the\nrectum were randomly divided into 2 equal groups the first group underwent\nconservative surgery by either rectal shaving or disc excision and the second group\nunderwent colorectal resection.\nResults We showed that rectal stenosis was more in the group of patients who are\nmanaged by segmental resection (some of patients with secondary stenosis\nunderwent secondary resection of colo-rectum and the others under general anesthe-\nsia had endoscopic dilatation.\nRisks of postoperative complication, as recto-vaginal fistula and dysfunction of the\nurinary bladder which required long term self-catheterization were more common in\nthe patients who underwent segmental resection.\nConstipation is recorded in (11.1%) of the conservative group and in (9.1%) of the\nsegmental resection group, frequent bowel movements is recorded in (8%) the\nconservative group and in 7 (22%) of the se gmental resection group, defecation\npain is recorded in (19%) of the conservative group and in 6 (19%) the segmental\nresection group, and involuntary loss of gas or stools were recorded in (12%) the\nreceived\nApril 26, 2025\naccepted after revision\nNovember 10, 2025\nDOI https://doi.org/\n10.1055/s-0045-1814452.\nISSN 2237-9363.\nEditor-in-Chief :H e n r i q u e\nFillmann.\n© 2026. The Author(s).\nThis is an open access article published by Thieme under the terms of the\nCreative Commons Attribution 4.0 International License, permitting copying\nand reproduction so long as the original work is given appropriate credit\n(https://creativecommons.org/licenses/by/4.0/)\nThieme Revinter Publicações Ltda., Rua Rego Freitas, 175, loja 1,\nRepública, São Paulo, SP, CEP 01220-010, Brazil\nTHIEME\nOriginal Article 1\nArticle published online: 2026-05-20\n\nIntroduction\nDeep infiltrating endometriosis is the presence of infiltration\nby endometrial glands and stroma deeply in the sub-perito-\nneal regions or muscle layer of hollow organs forms 10% of\ndeep endometriosis, which occurs in females in the child-\nbearing age. It is usually associated with the presence of\novarian endometriomas and peritoneal endometriosis.\n1\nPatients with such problems usually complain of; dysmenor-\nrhea, chronic pelvic pain, dyspareunia, primary or secondary\ninfertility, urinary tract and gastrointestinal complaints\nwhich negatively affect life quality. 2\nDeep in filtrating endometriosis is complicated by dense\nfibrosis, severe pelvic adhesions which results in normal\nanatomy distortion. Aim of management to carefully remove\nthe lesions, restore normal anatomy, and promote preserve\nor restore fertility.\n3\nRectal deep in filtrating endometriosis has become an in-\ncreasing problem with two main management strategies 4;\nradical surgery by segmental colorectal resection, and a con-\nservative surgery that includes removal of the lesion with\nrectal conservation.\n5 There are different conservation\napproaches as lesion shaving without opening the rectum, 6\na d d i t i o n a l l yt h en o d u l e sw h i c hs u r r o u n dt h ew a l lo ft h e\nrectum could be removed by full thickness resection or disc\nexcision.\n7\nIt was previously demonstrated that although radical\nsurgical excision leads to a complete removal of all\nlesions but the conservative management with rectal pres-\nervation improved the digestive functions.\n8 There are many\nstudies evaluated bene fits and drawbacks of one of the\nperformed approaches. 9–11 But, there are no suf ficient data\nregarding comparative studies between both management\nstrategies.\nAim was to compare between conservative management\nof deep in filtrating endometriosis of the rectum by shaving\nor disc excision and segmental radical colorectal resection\nregarding short term patients ’ outcome, digestive and uri-\nnary outcomes.\nPatients and Methods\nIn the present retrospective, comparative and randomized\nstudy we included patients with deep in filtrating rectal\nendometriosis in the period between March 2019 and Janu-\nary 2023 we divided them according to management\napproaches into two groups the first group underwent\nconservative rectal surgery and the other group underwent\nsegmental resection.\nInclusion Criteria\nPatients aged from 20-40 years with clinical, endoscopic,\nsonographic and radiological MRI evidence of deep endome-\ntriosois in filtrating the rectum about 2 cm length, up to\n15 cm from anus, more than half of the thickness of the\nmuscle layer of rectum and up to half of rectal circumference.\nWe explained the study aim and principles to included\npatients and written informed consents were acquired from\nall patients to be included in the study.\nApproval to perform the study was acquired from institu-\ntional review board of Faculty of Medicine, Zagazig\nUniversity.\nIncluded 60 patients were randomly divided into 2 equal\ngroups the first group underwent conservative surgery by\neither rectal shaving or disc excision and the second group\nunderwent colorectal resection.\nWe collect all baseline data of patients as; demographic,\nurinary, gastrointestinal and pelvic manifestations.\nSurgical Procedures\nManagement procedures of the conservative group of\npatients underwent surgical management of deep endome-\ntriosis of the rectum by performing shaving or performing\ndisc excision.\nWe performed shaving of nodules by; ultrasound scalpel,\nscissors, or using plasma energy,\n12 up to total excision of any\ngrossly detected nodules. We opened deep sub-peritoneal\nspace which is found between the rectum and uterosacral\nligament longitudinally, to avoid hypo-gastric and splanch-\nnic nerves injury.\nWe performed disc excision by using trans-anal stapler or\nby a direct approach through the vagina if it was opened for\nremoving nodules in filtrating the vagina.\n12\nWe started the process of disc excision by performing\nrectal shaving, as previously mentioned. Then if we found the\narea of rectum that is shaved was still in filtrated by the\nendometriotic nodules. Then we achieved full thickness\nexcision of the disc, by transanal approach.\nChoosing to perform either shaving and/or disc excision\ndepends on patient state and surgeon.\n13\nManagement procedures of the radical group of patients\nunderwent surgical management of in filtrating rectal endo-\nmetriosis by performing segmental resection of the colo-\nconservative group and in (30%) in the segmental resection group. Spontaneous\nconception was recorded in (70%) and (60%) of patients in both groups respectively.\nConclusion we showed a slightly better outcome of patient who underwent conser-\nvative surgery for deep in filtrating endometriosis of rectum management and it might\nimproves functional digestive and urinary outcomes, in comparison to resection of\ncolo-rectum.\nJ Coloproctol Vol. 46 No. 1/2026 © 2026. The Author(s).\nConservative vs. Rectal Surgery in Deep Endometriosis Eltaher etal.2\n\n\nrectum, in addition to resection of different parts of colon or\nsmall bowel whenever indicated. 14–16\nWe have dissected through the recto-vaginal septum.\nMultidisciplinary team that was composed of gynecologic\nand general surgeons who were experienced in performing\ncolorectal surgeries performed these surgical procedures.\nWe assessed the patient in a postoperative visit about 6 –\n12 weeks after performing the surgical procedure for assess-\ning immediate postoperative outcome and management of\nany postoperative complications as assessed by Clavien –\nDindo classi fication.\n17\nOutcomes\nAfter performing surgeries were followed patients at 6, 12,\n18 and 24 month for assessment of digestive and urinary\noutcomes.\nPrimary evaluated endpoints after surgery by about\n24 months were; constipation (1 stool/ > 5 days), frequent\nbowel movements ( /C214 stools/day), pain during defecation,\nanal incontinence, dysuria or bladder atony, bladder voiding\nby self-catheterization.\nSecondary evaluated endpoints after surgery were; VAS,\nKESS, GIQLI, Wexner, USP, SF36 scores.\nStatistical Analysis\nStatistical analyses were carried out using SAS 9.3 software\n(Cary, NC). To compare between the 2 included groups\nregarding treatment strategies by detecting the presence\nof functional symptoms at certain time, we used Fisher ’s\nexact test for categorical characteristics, we used Wilcoxon ’s\ntest. P-value was <0.05 was considered signi ficant.\nResults\nWe included 60 patients in our study then we randomly\ndivided them into 2 groups the first group included 30\npatients were managed by conservative surgery and\nthe second group included 30 patients and was managed\nby segmental resection.\nThere is statistically non-signi ficant difference between\nthe studied groups regarding age, VAS score, GLIQI, Wexner\nscore, preoperative symptoms, number of rectal nodule,\nlargest diameter of rectal nodule, distance from anal verge\nor deepest in filtrating layer\nWe analyzed included patients for the primary outcome.\nWe detected multifocal rectal endometriosis in 50% of\npatients.\nIn the first group of patients that are managed by conser-\nvative surgery underwent disc excision by Rouen technique,\ndisc excision using a trans-anal end-to-end circular stapler\nand direct trans-vaginal disc excision.\nAssessment of Postoperative outcomes and compli-\ncations:\nWe showed that stenosis of the rectum was more\nin the group of patients who are managed by segmental\nresection (some of patients with secondary stenosis\nunderwent secondary colorectal resection and the others\nhad endoscopic dilations under general anesthesia).\nRisks of postoperative complication, as recto-vaginal fis-\ntula and bladder dysfunction which required long term self-\ncatheterization were more common in the patients who\nunderwent segmental resection.\nThere is statistically non-signi ficant difference between\nthe studied groups regarding operative time, estimated\nblood loss, length of rectal segment, highest of colorectal\nanastomosis, or temporary stoma\nFunctional post-operative digestive symptoms in includ-\ned groups\nConstipation is recorded in (11.1%) of the conservative\ngroup and in (9.1%) of the segmental resection group,\nfrequent bowel movements is recorded in (8%) the conser-\nvative group and in 7 (22%) of the segmental resection group,\ndefecation pain is recorded in (19%) of the conservative\ngroup and in 6 (19%) the segmental resection group, and\ninvoluntary loss of gas or stools were recorded in (12%) the\nconservative group and in (30%) in the segmental resection\ngroup. As regards secondary outcomes, the values of KESS,\nGIQLI, Wexner, USP, SF36 and VAS scores were comparable\nbetween the two arms.\nThere is statistically signi ficant decrease in VAS score of\ndysmenorrhea, dyspareunia, pelvic pain, dyschezia and Wex-\nner incontinence score. There is statistically signi ficant in-\ncrease in GLIQI score Which denoted better outcome\nDuring the follow-up period of 24 months patients in both\nincluded groups attempted pregnancy: (50%) in the conser-\nvative surgery group and in the segmental resection group\n(65%). Among them, (70%) and (50%) of them conceived\nduring the follow-up respectively. Spontaneous conception\nwas recorded in (70%) and (60%) of patients in both groups\nrespectively.\nSpontaneous conception was recorded in (70%) and (60%)\nof patients in both groups respectively.\nDiscussion\nIn the present study we compared between patients under-\nwent conservative management and patients underwent\nsegmental resection in deep infiltrating pelvic endometriosis\nwhich mainly in filtrates the rectum. We showed a slightly\nbetter outcome of patient who underwent conservative\nmanagement than patient underwent de finitive segmental\nresection. Previous comparative reports showed variable\nresults; some studies demonstrated better functional out-\ncomes after performing conservative surgery.\n10 Other stud-\nies showed there were no statistically signi ficant differences\nbetween conservative surgery and de finitive surgical resec -\ntion regarding; functional, digestive and urinary symptoms. 4\nRegarding immediate post-operative complications, we\nshowed that there is a higher risk of occurrence of rectal\nstenosis in patients who underwent segmental colorectal\nresection and they required additional surgical or endoscop-\nic intervention.\nIn our study we included patients with only large endo-\nmetrial nodules as most surgeons considered de finitive\nJ Coloproctol Vol. 46 No. 1/2026 © 2026. The Author(s).\nConservative vs. Rectal Surgery in Deep Endometriosis Eltaher etal. 3\n\n\nsurgical management by segmental resection is an overtreat-\nment in management of small rectal nodules.\nPoints of Strengths\nInclusion of patients with nearly similar data, that were\nmanaged by quali fied surgeons.\nWe carefully followed up and assessed all included\npatients for accurate results.\nPrevious studies showed that during post-operative as-\nsessment of digestive functions, complete removal of deep\ninfiltrating endometriosis of the rectum has no roles in\nrelieving digestive symptoms.\n18,19 Which is similar to our\nfindings that bowel resection has no bene fits in improving\nbowel functions.\nOur findings are slightly different from findings of few\nprevious studies that demonstrated improvement of post-\noperative digestive functional outcomes. But, these variable\nfindings might be due to inclusion of patients with severe\ninfiltrating endometriosis which were managed by resection\nof colorectum and patients with smaller nodules which were\nmanaged by nodules shaving.\nDeep infiltrating endometriotic nodules of rectum remov-\nal by disc excision or by shaving, lead to preservation of\nmesorectum and rectal neurovascular supply without mod-\nifications in rectum overall length, but all these advantages\nmight have no major positive effect on rectal function after\nthe operation, in comparison with colorectal resection.\n20,21\nThese findings might have many explanations; deep in fil-\ntrating endometriosis of the rectum might also affect ute-\nrosacral ligaments, parametrium, vagina, inferior\nhypogastric plexus and also splanchnic nerves. Additionally\ncomplete local conservative resection of large in filtrating\nendometriotic nodules lead to postoperative dysfunction of\nvegetative nerves.\n21–25\nFurthermore, postoperative dysfunction of rectal or uri-\nnary bladder, 26 which were found to be irreversible and\ncould not restored by nodules removal.\nColorectal resection was priously demonstrated to be\nassociated with higher risks of rectovaginal leakage and\nfistula in comparison to shaving. 27 Rates of pregnancy and\npostoperative spontaneous conceptions after 24 months in\nboth groups were nearly similar.\nNone of our patients showed any endometriosis recur-\nrence during the 24 months following the surgery.\nIn conclusion, we showed a slightly better outcome of\npatient who underwent conservative surgical management\nof deep endometriosis in filtrating rectal wall and it might\nimproves functional digestive and urinary outcomes, in\ncomparison to radical resection of colon or rectum. More-\nover, surgical resection of colorectal endometriosis might\nbe safely performed to young female patients with severe\nendometriosis and pregnancy intention, but it should\nbe kept in mind that; resection of the colorectum is\nresponsible for a higher rate of bowel stenosis that might\nrequire redo procedures, under general anesthesia. Finally\npatients should be informed that there is a risk of abnormal\nbowel movements in 40% of cases regardless of surgical\nmanagement.\nRecommendations\nAs recurrence of endometriosis might happen after 2 years,\nwe recommend performing a large scale study included\nlarger number of cases with a follow-up period of more\nthan 2 years to detect effect of both procedures on disease\nrecurrence.\nContributions of the Authors\nConflicts of Interest\nAuthors declared no con flicts of interest\nData Availability\nData will be available upon request to the corresponding\nauthor.\nReferences\n1 Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic\nsystemic disease: clinical challenges and novel innovations. Lan-\ncet 2021;397(10276):839 –852\n2 Zhang S, Yu H, Dong Z, et al. Laparoendoscopic single-site surgery\nfor deep in filtrating endometriosis based on retroperitoneal\npelvic spaces anatomy: a retrospective study. Sci Rep 2023;13\n(01):10785\n3 Saunders PTK, Horne AW. Endometriosis: Etiology, pathobiology,\nand therapeutic prospects. Cell 2021;184(11):2807 –2824\n4 Roman H, Bubenheim M, Huet E, et al. Conservative surgery\nversus colorectal resection in deep endometriosis in filtrating\nthe rectum: a randomized trial. Hum Reprod 2018;33(01):47 –57\n5 Roman H, Vassilieff M, Tuech JJ, et al. Postoperative digestive\nfunction after radical versus conservative surgical philosophy for\ndeep endometriosis in filtrating the rectum. Fertil Steril 2013a;99\n(06):1695–1704\n6 Donnez J, Squif flet J. Complications, pregnancy and recurrence in\na prospective series of 500 patients operated on by the shaving\ntechnique for deep rectovaginal endometriotic nodules. Hum\nReprod 2010;25(08):1949 –1958\n7 Fanfani F, Fagotti A, Gagliardi ML, et al. Discoid or segmental\nrectosigmoid resection for deep in filtrating endometriosis: a\ncase-control study. Fertil Steril 2010;94(02):444 –449\n8 Roman H, Milles M, Vassilieff M, et al. Long-term functional\noutcomes following colorectal resection versus shaving for rectal\nendometriosis. Am J Obstet Gynecol 2016;215(06):762.e1 –762.e9\n9 De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P.\nBowel resection for deep endometriosis: a systematic review.\nBJOG 2011;118(03):285 –291\n10 Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C.\nDeep endometriosis infiltrating the recto-sigmoid: critical factors\nto consider before management. Hum Reprod Update 2015;21\n(03):329–339\n11 Meuleman C, Tomassetti C, D ’Hoore A, et al. Surgical treatment of\ndeeply in filtrating endometriosis with colorectal involvement.\nHum Reprod Update 2011;17(03):311 –326\n12 Roman H, Darwish B, Bridoux V, et al. Functional outcomes after\ndisc excision in deep endometriosis of the rectum using transanal\nstaplers: a series of 111 consecutive patients. Fertil Steril\n2017a;107(04):977–986.e2\n13 Millochau JC, Stochino-Loi E, Darwish B, et al. Multiple nodule\nremoval by disc excision and segmental resection in multifocal\ncolorectal endometriosis. J Minim Invasive Gynecol 2018;25(01):\n139–146. Doi: 10.1016/j.jmig.2017.09.007\n14 Darai E, Thomassin I, Barranger E, et al. Feasibility and clinical\noutcome of laparoscopic colorectal resection for endometriosis.\nAm J Obstet Gynecol 2005;192(02):394 –400\nJ Coloproctol Vol. 46 No. 1/2026 © 2026. The Author(s).\nConservative vs. Rectal Surgery in Deep Endometriosis Eltaher etal.4\n\n\n15 Dousset B, Leconte M, Borghese B, et al. Complete surgery for low\nrectal endometriosis: long-term results of a 100-case prospective\nstudy. Ann Surg 2010;251(05):887 –895\n16 Minelli L, Fanfani F, Fagotti A, et al. Laparoscopic colorectal resection\nfor bowel endometriosis: feasibility, complications, and clinical\noutcome. Arch Surg 2009;144(03):234–239, discussion 239\n17 Dindo D, Demartines N, Clavien PA. Classi fication of surgical com-\np l i c a t i o n s :an e wp r o p o s a lw i t he v a l u a t i o ni nac o h o r to f6 3 3 6\npatients and results of a survey. Ann Surg 2004;240(02):205–213\n18 Kupelian AS, Cutner A. Segmental bowel resection for deep\ninfiltrating endometriosis. BJOG 2016;123(08):1368\n19 Riiskjaer M, Greisen S, Glavind-Kristensen M, Kesmodel US, For-\nman A, Seyer-Hansen M. Pelvic organ function before and after\nlaparoscopic bowel resection for rectosigmoid endometriosis: a\nprospective, observational study. BJOG 2016;123(08):1360 –1367\n20 Roman H, Bridoux V, Tuech JJ, et al. Bowel dysfunction before and\nafter surgery for endometriosis. Am J Obstet Gynecol 2013b;209\n(06):524–530\n21 Darwish B, Roman H. Nerve sparing and surgery for deep in fil-\ntrating endometriosis: pessimism of the intellect or optimism of\nthe will. Semin Reprod Med 2017;35(01):72 –80\n22 Possover M. Pathophysiologic explanation for bladder retention\nin patients after laparoscopic surgery for deeply in filtrating\nrectovaginal and/or parametric endometriosis. Fertil Steril\n2014;101(03):754–758\n23 Bonneau C, Zilberman S, Ballester M, et al. Incidence of pre- and\npostoperative urinary dysfunction associated with deep in filtrat-\ning endometriosis: relevance of urodynamic tests and therapeutic\nimplications. Minerva Ginecol 2013;65(04):385 –405\n24 de Resende JA, Cavalini LT, Crispi CP, de Freitas Fonseca M. Risk of\nurinary retention after nerve-sparing surgery for deep in filtrating\nendometriosis: A systematic review and meta-analysis. Neuro-\nurol Urodyn 2017;36(01):57 –61\n25 Ceccaroni M, Clarizia R, Bruni F, et al. Nerve-sparing laparoscopic\neradication of deep endometriosis with segmental rectal and\nparametrial resection: the Negrar method. A single-center, pro-\nspective, clinical trial. Surg Endosc 2012;26(07):2029 –2045\n26 Mabrouk M, Ferrini G, Montanari G, et al. Does colorectal endo-\nmetriosis alter intestinal functions? A prospective manometric\nand questionnaire-based study. Fertil Steril 2012;97(03):\n652–656\n27 Roman HFRIENDS group (French coloRectal In filtrating ENDome-\ntriosis Study group) A national snapshot of the surgical manage-\nment of deep in filtrating endometriosis of the rectum and colon\nin France in 2015: A multicenter series of 1135 cases. J Gynecol\nObstet Hum Reprod 2017b;46(02):159 –165\nJ Coloproctol Vol. 46 No. 1/2026 © 2026. The Author(s).\nConservative vs. Rectal Surgery in Deep Endometriosis Eltaher etal. 5","source_license":"CC0","license_restricted":false}