{"paper_id":"e90fea77-8772-4207-aaba-84c9fe9958bb","body_text":"Middle East J Rehabil Health Stud. 2025 January; 12(1): e151847 https://doi.org/10.5812/mejrh-151847\nPublished Online: 2024 November 27 System atic Review\nCopyright ©  2025, Abdi et al. This open-access article is available under the Creative Commons Attribution 4.0 (CC BY 4.0) International License\n(https://creativecommons.org/licenses/by/4.0/), which allows for unrestricted use, distribution, and reproduction in any medium, provided that the original\nwork is properly cited.\nRecurrence and Pregnancy Rate After Surgery Treatment of Deep\nInfiltrating Endometriosis: A Systematic Review and Meta-analysis\nFatemeh Abdi \n 1 , 2 , Zainab Alimoradi 3 , Nastaran Safavi Ardabili 4 , Elham Shirdel 5 , Farinaz Rahimi 6 ,\nNarges Mirzadeh 7 , Fatemeh Alsadat Rahnemaei \n 8 , *\n1 Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran\n2 Nursing and Midwifery Care Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran\n3 Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical\nSciences, Qazvin, Iran\n4 Department of Midwifery, Ardabil Branch, Islamic Azad University, Ardabil, Iran\n5 Department of Midwifery, North Khorasan University of Medical Sciences, Bojnurd, Iran\n6 Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran\n7 School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran\n8 Reproductive Health Research Center, Guilan University of Medical Sciences, Rasht, Iran\n*Corresponding Author: Reproductive Health Research Center, Guilan University of Medical Sciences, Rasht, Iran. Email: f_rahnemaie@yahoo.com\nReceived:1August, 2024;Revised:4November, 2024;Accepted:4November, 2024\nAbstract\nContext: Deep infiltrating endometriosis (DIE) is a specific form of endometriosis in women, causing infertility and pelvic\npain during reproductive age. Surgery is the treatment of choice for managing DIE, as medical therapy alone cannot adequately\ncontrol symptoms.\nO bjectives: The present study aims to investigate the recurrence and pregnancy rates following surgical treatment of DIE in\nwomen of reproductive age.\nMethods: PubMed, Web of Science, Scopus, Google Scholar, Cochrane Library, and ProQuest databases were searched from 2010\nto August 25th, 2024, using appropriate MeSH keywords. The quality of the included studies was assessed using the Mixed\nMethod Appraisal Tool (MMAT), version 2018.\nResults: A total of 41 studies were included in the systematic review, and 34 studies were included in the meta-analysis. The\nmeta-analysis comprised 6,585 individuals from 14 countries. The pooled estimated prevalence of endometriosis recurrence was\n13% (95% CI: 11–17%, I²: 96.5%, Tau²: 0.01, Observations: 35). The corrected pooled estimated pregnancy rate after surgery for\nendometriosis was 47% (95% CI: 36–57%, I²: 96.47%, Tau²: 0.05).\nConclusions: Recurrence and pregnancy rates remain controversial challenges in the surgical management of DIE. This study\nindicates a relatively low recurrence rate after DIE surgery and an improvement in the approximate pregnancy rate following\nthe surgical approach.\nKeywords:Deep Infiltrating Endometriosis,DIE,Recurrence,Pregnancy Rate\n1. Context\nEndometriosis is a chronic condition in women\ncharacterized by the abnormal growth of endometrial\ntissue outside the uterine cavity or myometrium (1). This\ncondition is associated with infertility, chronic pelvic\npain, and asymptomatic presentations in 31%, 42%, and\n23% of cases, respectively, among women of\nreproductive age (2). Deep infiltrating endometriosis\n(DIE) is a severe form of endometriosis, defined by the\ninfiltration of endometrial-like tissue into the deeper\nlayers of the pelvic organs and tissues (3). Deep\ninfiltrating endometriosis typically involves specific\nareas such as the rectovaginal septum, uterosacral\nligaments, pararectal space, and vesicoureteral fold.\nHowever, it may also affect the rectum, sigmoid colon,\nileum, ureter, diaphragm, and other less common\nlocations (4). Among symptoms, dysmenorrhea is the\n\nAbdi F et al. Brieflands\n2 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nmost frequent type of pain experienced by women with\nendometriosis (5, 6). Deep infiltrating endometriosis is\nalso strongly associated with pelvic pain and\ndyspareunia (7).\nMedical managementof endometriosis includes\ntreatments such as danazol, progesterone medications,\ngestrinone, combined estrogen and progesterone\nformulations, gonadotropin-releasing hormone\nagonists, and other comparable options (8). However,\nsurgical intervention remains the most effective\napproach for managing DIE (9) due to the limitations of\nmedical therapy in controlling symptoms. Studies have\nshown that while surgery can significantly alleviate\npain, there remains a risk of disease recurrence across\nall stages of the condition. Various laparoscopic\napproaches have been utilized for the treatment of\nbowel endometriosis, including shaving, disc excision,\nand segmental resection (10). However, no definitive\nevidence has established the superiority of one surgical\ntechnique over another, as limited medium-term\nstudies compare safety, effectiveness, and recurrence\nrates among these techniques (11).\nRecurrence is defined as the reappearance of\nsymptoms and signs following treatment and remission\nand varies depending on the duration of follow-up (12).\nEvidence suggests that surgery alone can effectively\ncontrol pain caused by endometriosis across all stages\nof the disease. On the other hand, the effectiveness of\ntreatment in women with endometriosis is often\nmeasured by reductions in pain and improvements in\ninfertility following treatment (13).\nGiven the increasing prevalence of endometriosis in\nrecent decades, addressing the knowledge gap in\ncurrent review studies and updating existing\ninformation is essential.\n2. O bjectives\nThis systematic review and meta-analysis aim to\ninvestigate the recurrence and pregnancy rates\nfollowing surgical treatment of DIE in reproductive-age\nwomen. Additionally, the study evaluates the\npreoperative and postoperative prevalence of common\naccompanying symptoms in these cases.\n3. Data Sources\n3.1. Study Design and Registration\nThis investigation was conducted following the\npreferred reporting items for systematic reviews and\nmeta-analyses (PRISMA) framework. The PRISMA\nguidelines include a total of 27 components, covering\nvarious aspects of systematic reviews and meta-analyses,\nsuch as abstracts, methods, results, discussions, and the\ndisclosure of financial resources (14).\nThis study was approved by the ethical code\nIR.ABZUMS.REC.1401.025 at Alborz University of Medical\nSciences. Furthermore, it was registered on the\nPROSPERO website under the ID \"CRD42022328051.\"\n3.2. Search Strategy\nPubMed, Web of Science, Scopus, Google Scholar,\nCochrane Library, and ProQuest were systematically\nsearched from 2010 to August 25, 2024. Initially, each\nkeyword was searched individually, followed by their\ncombination using \"AND\" or \"OR\" to create new\nkeywords or phrases. The search strategy, employing\nMeSH keywords, is outlined below:\n'Deep endometriosis'[tiab] OR, 'Deep infiltrating\nendometriosis'[tiab] OR, 'DIE'[tiab], OR 'Bowel\nendometriosis'[tiab] OR, 'Colorectal endometriosis'[tiab]\nOR, 'Rectovaginal endometriosis'[tiab] OR, 'Bladder\nendometriosis'[tiab] OR, 'Ureteral endometriosis'[tiab]\nOR, 'Diaphragmatic endometriosis'[tiab], OR\n'Endometrioma'[tiab], OR 'Endometriomas'[tiab], AND\n'Surgery'[tiab], OR 'Surgery treatment'[tiab], AND\n'Recurrence'[tiab], OR 'Recrudescence'[tiab], OR\n'Recrudescences' [tiab], OR, 'Relapse'[tiab],\n'Relapses'[tiab], AND 'Fertility rate' [tiab], OR 'pregnancy\nrate'[tiab].\n3.3. Eligibility Criteria\nEligibility criteria were established based on the\nPICO-S framework, where P represents the population\n(reproductive-age women), I represents the intervention\n(surgical procedures), C represents the comparison\n(without comparison), O represents the outcome\n(recurrence and pregnancy rates), and S represents the\nstudy design [cohort, cross-sectional, and randomized\nclinical trials (RCTs)]. Studies published up to August\n25th, 2024, with full-text availability in English or\nPersian, were included. Exclusion criteria comprised\nletters, comments, short communications, conference\nabstracts, grey literature, review studies, and other\nirrelevant studies.\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 3\n3.4. Study Selection\nTo achieve the final results presented in Table 1, a\nsystematic process was initiated. The titles and abstracts\nof all retrieved studies were screened based on the\ninclusion criteria. In the next step, the full texts of the\neligible abstracts were evaluated, and if the full text was\ninaccessible, an email was sent to the corresponding\nauthor. Subsequently, the full texts of eligible studies\nwere thoroughly examined according to the specified\ncriteria, and relevant studies were selected for analysis.\nThis process was conducted independently by two\nreviewers, and any disagreements were resolved\nthrough discussion. In cases where the study content\nwas unclear, the authors were contacted directly for\nclarification.\n3.5. Quality Assessm ent\nThe studies were evaluated using the Mixed Methods\nAppraisal Tool (MMAT), version 2018. This tool is\nspecifically designed to assess the quality of empirical\nstudies, including primary research based on\nexperiments, observations, or simulations. Its primary\npurpose is to provide a systematic approach for\nappraising the quality of these studies (54, 55). The tool\ncomprises five items for each category, with responses\nmarked as \"yes,\" \"no,\" or \"not known.\" In the scoring\nsystem, a \"yes\" answer is scored as 1, while all other\nresponses are scored as 0. A higher score indicates\nhigher quality. For the final quality assessment, scores\nabove half (more than 50%) were considered high\nquality (Table 2).\n3.6. Data Extraction\nTwo researchers independently conducted the study\nselection and validity assessment, resolving any\ndiscrepancies by consulting a third researcher. The\nstudies extracted information on various parameters,\nincluding author, year, study design, country, age,\nnumber of participants, Body Mass Index (BMI),\nsymptoms, location of endometriosis, surgical\ntechniques, recurrence rate, post-surgical pregnancy\nrate, and follow-up duration (Table 1).\n3.7. Data Synthesis\nA comprehensive analysis was conducted by\nperforming a quantitative synthesis using STATA\nsoftware version 17. The random-effects model was\nemployed for the meta-analysis due to the inclusion of\nstudies from diverse populations. This model accounts\nfor both within-study and between-study variances,\nthereby ensuring a thorough analysis (56). The Q\nCochrane statistic was used to evaluate heterogeneity,\nwhile the I² index was utilized to quantify the extent of\nheterogeneity. Heterogeneity was interpreted as (i) mild\nif the I² value is below 25%, (ii) moderate if the I² value\nranges from 25% to 50%, (iii) severe if the I² value falls\nbetween 50% and 75%, and (iv) highly severe if the I²\nvalue exceeds 75% (57).\nThe key measures selected for this study were the\nprevalence of endometriosis and the pregnancy rate\nafter surgery. To determine the overall prevalence,\nnumerical findings for these conditions were combined,\nand a pooled prevalence was calculated. Additionally, a\n95% confidence interval (CI) was provided to indicate the\nrange of possible prevalence values.\nTo evaluate moderator effects, subgroup analysis, or\nmeta-regression, an assessment was performed\nconsidering the number of studies in each group. In\ncases where the number of studies in a particular group\nwas fewer than four, meta-regression was employed.\nPublication bias was assessed using a funnel plot, as well\nas Begg's Test and Egger's Test (58). Sensitivity analysis\nwas conducted using the Jackknife method (59).\n4. Results\n4.1. Study Screening & Selection Process\nThe initial search yielded 4,610 results. Two authors\nindependently evaluated the eligibility of these studies,\nwith disagreements resolved through consensus by\nconsulting a third author. In the first stage, 2,680\nirrelevant or duplicate articles were excluded. After\nreviewing the titles and abstracts of the remaining\narticles, additional papers were excluded. Ultimately, a\ntotal of 41 eligible studies were systematically reviewed,\nand 34 studies met the criteria for inclusion in the meta-\nanalysis (Figure 1). Key findings from the included\nstudies are summarized in Table 1.\n4.2. Studies Characteristics\nThirty-four papers, comprising 6,514 individuals from\n14 countries (e.g., Australia, Brazil, China, Egypt, France,\nGermany, Iran, Israel, Italy, Korea, Spain, Switzerland,\nSlovenia, and the USA), were included in the analysis\nregarding endometriosis recurrence. The two countries\nwith the highest number of eligible studies were France\n\nAbdi F et al. Brieflands\n4 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nTable 2. Appraising of the 41 Studies Based on Mixed Method Appraisal Tool; Version 18 a\nSelected Studies AppraisalQuality\nQuantitative Non-random ized Criteria\nAre the ParticipantsRepresentative of the TargetPopulation?\nAre Measurem ents Appropriate RegardingBoth the O utcom e and Intervention (orExposure)?\nAre ThereCom pleteO utcom e Data?\nAre the ConfoundersAccounted for in the Designand Analysis?\nDuring the Study Period, Is theIntervention Adm inistered (or ExposureO ccurred) as Intended?\nMissori, et al. ( 15) H Y Y Y Y Y\nHan, et al. ( 16) H Y Y Y Y Y\nZhang, et al. ( 17) H Y Y Y Y Y\nYang, et al. ( 18) H Y N Y C Y\nLeborne, et al. ( 19) H Y Y Y Y Y\nZhang et al. ( 20) H Y Y Y C Y\nKim  et al. ( 21) H Y Y Y Y Y\nRom an et al. ( 22) H Y Y Y C Y\nCeccaroni, et al.\n( 23) H Y Y Y Y Y\nSarbazi, et al. ( 24) H Y Y Y Y Y\nYela, et al. ( 25) H Y Y Y Y Y\nVidal, et al. ( 26) H Y Y Y Y Y\nParra, et al. ( 27) H Y Y Y Y Y\nJayot, et al. ( 28) H Y Y Y Y Y\nAbesadze, et al.\n( 29) H Y Y Y C Y\nCeccaroni, et al.\n( 30) H Y Y Y Y Y\nAbesadze, et al. ( 31) H Y Y Y C Y\nSun, et al. ( 32) H Y Y Y C Y\nNirgianakis, et al.\n( 33) H Y Y N Y Y\nCeccaroni, et al.\n( 34) H Y Y Y Y Y\nZheng, et al. ( 35) H Y C Y C Y\nShaltout, et al. ( 36) H Y Y Y C Y\nRom an, et al. ( 37) H Y Y Y C Y\nHernandez\nGutierrez, et al. ( 9) H Y Y Y Y Y\nRom an, et al. ( 38) H Y Y Y Y Y\nSaavalainen, et al.\n( 39) H Y Y Y Y Y\nRom an, et al. ( 40) H Y Y Y Y Y\nRom an, at al. ( 41) H Y Y Y C Y\nAfors, et al. ( 42) H Y Y Y Y Y\nCao, et al. ( 43) H Y Y Y N Y\nCollinet, et al. ( 44) H Y Y Y Y Y\nU ccella, et al. ( 45) H Y Y Y Y Y\nRuffo, et al. ( 11) H Y Y Y Y Y\nNirgianaki, et al.\n( 46) H Y Y Y C Y\nNezhat, et al. ( 47) H Y Y Y N C\nMangler, et al. ( 48) H Y Y Y Y C\nNem e, et al. ( 49) H Y Y Y C C\nSchonm an, et al.\n( 50) H Y Y C N Y\nMabrouk, et al.\n( 51) H Y Y Y Y Y\nKoh, et al. ( 52) H Y Y Y Y Y\nJelenc, et al. (53) H Y Y Y C Y\na Scoring: Y, yes, N, no, C, can’t tell, H, high.\n(n = 7) and Italy (n = 5). The smallest sample size was 7\nparticipants, and the largest sample size was 1,332.\nThe mean age of participants was 33.92 years, with a\nrange of 27.5 to 41 years (reported in 34 studies). The\nmean BMI of participants was 23.18 kg/m², with a range\nof 20.9 to 26.9 kg/m² (reported in 22 studies). The mean\nfollow-up duration was 43.21 months, ranging from 10 to\n120 months (reported in 35 studies). The most frequently\nreported endometriosis lesion sites were bowel (n = 9),\nrectal (n = 8), and DIE (n = 7).\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 5\nFigure 1. The literature search results and the screening process based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart\nFigure 2. The pooled estimated prevalence of endometriosis recurrence\n4.3. Endom etriosis Recurrence\nThe pooled estimated prevalence of endometriosis\nrecurrence was 13% [95% CI: 11 - 17%, I²: 96.5%, Tau²: 0.01,\nObservations: 35]. Figure 2 presents the forest plot\nillustrating the pooled prevalence of endometriosis\nrecurrence across the included studies.\nBased on Egger’s test (P = 0.056) and the asymmetric\nfunnel plot (Figure 3), the likelihood of publication bias\nappeared probable. To further evaluate this, the fill-and-\ntrim method was applied. Using this method, no\nadditional studies were imputed, and the probability of\npublication bias was ultimately ruled out.\nAdditionally, sensitivity analysis (Figure 4) indicated\nthat the pooled effect size was not influenced by the\neffect of any single study.\n\nAbdi F et al. Brieflands\n6 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nFigure 3. Funnel plot\nFigure 4. Sensitivity analysis\n4.4. Pregnancy Rate After Surgery\nTwenty-two papers, comprising 2,039 individuals\nwith infertility from nine countries (e.g., Brazil, China,\nFinland, France, Germany, Israel, Italy, Iran, and\nSlovenia), were included in the analysis of pregnancy\nrates after surgery for endometriosis. The highest\nnumber of eligible studies were from China (n = 6). The\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 7\nFigure 5. Pooled estimated pregnancy rate after surgery for endometriosis\nFigure 6. Publication bias\nsmallest sample size was 7 participants, and the largest\nwas 774.\nThe mean age of participants was 33.44 years,\nranging from 27.5 to 37 years (reported in 22 studies).\nThe mean BMI of participants was 23.41 kg/m², ranging\nfrom 20.9 to 25.7 kg/m² (reported in 15 studies). The\nmean follow-up duration was 44.30 months, ranging\nfrom 10 to 120 months (reported in 22 studies). The most\n\nAbdi F et al. Brieflands\n8 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nFigure 7. Probable publication bias\nfrequently reported endometriosis lesion sites were DIE\n(n = 8 studies).\nThe pooled estimated pregnancy rate after surgery\nfor endometriosis was 47% [95% CI: 36 - 57%, I²: 96.47%,\nTau²: 0.05]. Figure 5 presents the forest plot illustrating\nthe pooled prevalence of pregnancy rates after surgery\nfor endometriosis across the included studies.\nBased on Egger’s test (P < 0.001) and the asymmetric\nfunnel plot (Figure 6), publication bias appears to be\nprobable.\nProbable publication bias was addressed using the\nfill-and-trim method. In this process, five studies were\nimputed, resulting in a corrected pooled prevalence of\nthe pregnancy rate after surgery for endometriosis of\n37.9% (95% CI: 26.8 - 48.9%). The funnel plot after\ntrimming is presented in Figure 7.\nSensitivity analysis (Figure 8) demonstrated that the\npooled effect size was not influenced by the effect of any\nsingle study. Based on meta-regression (Table 3), none of\nthe examined variables significantly predicted the\nprevalence of the pregnancy rate after surgery for\nendometriosis.\nThe pooled estimated prevalence of preoperative\ndysmenorrhea was 78% (22 papers, 95% CI: 64 - 92%, I²:\n99.40%, Tau²: 0.11), while postoperative dysmenorrhea\nwas 24% (8 papers, 95% CI: 14 - 34%, I²: 97.51%, Tau²: 0.02).\nThe pooled estimated prevalence of preoperative\nchronic pelvic pain was 50% (17 papers, 95% CI: 35 - 64%, I²:\n98.98%, Tau²: 0.09), and postoperative chronic pelvic\npain was 31% (7 papers, 95% CI: 15 - 37%, I²: 96.21%, Tau²:\n0.04).\nThe pooled estimated prevalence of preoperative\ndyspareunia was 56% (20 papers, 95% CI: 42 - 71%, I²:\n98.91%, Tau²: 0.10), while postoperative dyspareunia was\n22% (6 papers, 95% CI: 5 - 39%, I²: 96.55%, Tau²: 0.04).\nThe pooled estimated prevalence of preoperative\ndyschezia was 44% (15 papers, 95% CI: 32 - 57%, I²: 98.19%,\nTau²: 0.06), and postoperative dyschezia was 21% (5\npapers, 95% CI: 5 - 36%, I²: 95.97%, Tau²: 0.03).\n5. Discussion\nIn this systematic review and meta-analysis, we\nidentified 41 studies evaluating pregnancy and\nrecurrence rates after surgical treatments in women\nwith DIE. The results demonstrated that the prevalence\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 9\nFigure 8. Sensitivity analysis\nTable 3. Meta Regression of Endometriosis Recurrence and Pregnancy Rate Based on Different\nVariables\nEndom etriosis Recurrence Pregnancy Rate\nNo. of Studies Coeff. S.E. P I2 res. (%) R 2 (%) Tau2 No. of Studies Coeff. S.E. P I2 res. (%) R 2 (%) Tau2\nCountry 35 0.002 0.005 0.61 95.44 0 0.009 22 0 .02 0.02 0.19 95.94 4.01 0.05\nStudy design 35 0.02 0.03 0.53 95.51 0 0.009 22 0.15 0.11 0.17 96.34 5.42 0.05\nMean age 34 0.002 0.005 0.78 94.25 0 0.009 22 -0.004 0.02 0.84 95.86 0 0.06\nMean BMI 22 0.02 0.01 0.18 91.98 3.13 0.006 15 0.05 0.05 0.38 97.01 0 0.06\nFallow up tim e 35 -0.001 0.0006 0.36 95.39 0.13 0.009 22 0.001 0.002 0.45 96.31 0 0.05\nEndom etriosis lesion site 35 0.008 0.007 0.21 95.31 1.97 0.009 22 0.02 0.02 0.49 96.14 0 0.05\nAbbreviation: BMI, Body Mass Index.\nof endometriosis recurrence was 13%, while the\npregnancy rate after surgery was estimated at 47%.\nAdditionally, we concluded that the postoperative\nprevalence of dysmenorrhea was 24%, chronic pelvic\npain 31%, dyspareunia 22%, and dyschezia 21%. Compared\nto preoperative rates, the prevalence of these symptoms\nhad decreased.\nA study investigating the efficacy of laparoscopic\nureteroneocystostomy in patients with DIE involving\nthe ureter, parametrial region, and bowel showed that\namong 60 patients with DIE, the recurrence rate was\nreported as 1.2% after six months of follow-up. This study\nconcluded that laparoscopic partial cystectomy for DIE\nis the gold standard treatment due to its low recurrence\nrate (30). Ferrero et al. (2020) examined the risk of\n\nAbdi F et al. Brieflands\n10 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nrecurrence after segmental resection for rectosigmoid\nendometriosis. After a five-year follow-up, imaging\ndetected rectosigmoid endometriosis recurrence in five\npatients. Surgical and histological diagnoses confirmed\nrecurrence in six out of seven patients (60).\nHernandez Gutierrez et al. (2019) compared\npostoperative complications and recurrence rates\namong three surgical techniques: Segmental resection,\ndiscoid excision, and nodule shaving. Their findings\nrevealed that segmental resection had a significantly\nhigher incidence of severe postoperative complications\ncompared to discoid excision or the shaving technique\n(23.5% versus 5% versus 0%, respectively). However, over\nan extended follow-up period, the shaving group\nexhibited a higher recurrence rate (12.7%) compared to\nthe discoid group (5%) and the segmental resection\ngroup (1.3%) (9).\nCao et al. (2015) evaluated the efficacy and safety of\ncomplete versus incomplete excision of DIE. Their\nresults indicated that recurrence rates were\nsignificantly higher in the incomplete excision group\n(29.4% vs. 3.9%) (43). A comprehensive analysis and meta-\nanalysis investigating recurrence following surgical\ntreatment for colorectal endometriosis found that the\nrisk of recurrence was higher after rectal shaving\ncompared to segmental resection and disc excision in\ncases with confirmed histological recurrence. However,\nno significant difference was observed between the\nrecurrence rates of disc excision and segmental\nresection (61).\nAnother review study highlighted that incomplete\nremoval of endometriosis is a major contributing factor\nto recurrence, as documented in the literature. The\nextent of lesion excision significantly influences\nrecurrent symptoms, especially based on the type of\nhysterectomy performed. Notably, no studies have\nspecifically compared recurrence rates of endometriosis\nfollowing standard hysterectomy with robotic-assisted\nhysterectomy (62).\nIn the present study, we reported an overall\nrecurrence rate of DIE after surgical procedures\n(regardless of the type of surgery and the location of\nendometriosis) as 13%. Several risk factors appear to\ninfluence the recurrence rate of endometriosis. These\nfactors include young women affected by the condition\nwho desire pregnancy but decline hormonal treatments\nfollowing surgery; the location of endometriosis,\nparticularly when it affects the bladder and uterus;\nwomen who are obese or overweight; the primary\nsurgical approach employed; and incomplete removal\nof lesions (7, 12). Additionally, the presence of\nmicroscopic satellite lesions adjacent to the main lesion,\nwhich may remain undetected during surgery, can\ncontribute to an increased incidence of recurrence (63,\n64).\nRegarding symptoms associated with DIE\n(dysmenorrhea, chronic pelvic pain, dyspareunia, and\ndyschezia), our findings showed that surgery improved\nthese symptoms compared to the preoperative\ncondition. When assessing pain in women with\nendometriosis during treatment trials, three factors are\ncrucial: The use of a valid pain scale, time-dependent\nassessment, and consideration of placebo or sham\nsurgery effects (61).\nJayot et al. (2020) investigated various factors in a\ngroup of patients who underwent discoid resection.\nThese factors included the conversion rate to segmental\nresection, the necessity for double discoid resection, and\nthe rates of complications and recurrence. Their\nfindings revealed no significant differences in\ncomplication rates or voiding dysfunction between\ndouble and single discoid resection groups (28).\nIn a 2006 analysis, the crude pain recurrence rate in\nwomen with endometriosis undergoing first-line\nconservative laparoscopic surgery was reported to be\n21%, and the crude disease relapse rate was 9% (5). Many\nstudies consider recurrence as the reappearance of pain;\nhowever, this definition has limitations due to the\nsubjective nature of pain evaluation (40). Although\nsurgical excision of endometriosis improves pain and\nenhances fertility, recurrence can exacerbate pain and\nreduce fertility, negatively impacting quality of life and\nincreasing personal and social costs.\nSurgical techniques may also influence symptom\nrecurrence. For example, a study revealed that\nindividuals who underwent hysterectomy with ovarian\nconservation for endometriosis had a significantly\nhigher risk of recurrent pain and reoperation compared\nto those who underwent oophorectomy. Specifically, the\nformer group had a 6.1-fold greater risk of recurrent\npain and an 8.1-fold greater risk of reoperation (65).\nAmong the strengths of this study are the following:\nSeparating the types of endometriosis and the surgical\ntechniques used for each type of lesion, examining\nother factors affecting endometriosis recurrence rates,\nsuch as BMI, and evaluating factors influencing the\neffectiveness of surgical methods, in addition to\nrecurrence rates, such as pregnancy rates\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 11\n(distinguishing between natural pregnancy and ART\nuse). Moreover, the study assessed the recurrence of\nsymptoms related to endometriosis, such as\ndysmenorrhea and dyspareunia.\nOne limitation of this study is the lack of separate\nrecurrence rate estimates for each surgical approach or\nfor each specific site of endometriosis. Future studies\nshould address these issues in their analyses.\nAdditionally, it is suggested to evaluate recurrence rates\nin cases where medical approaches are used post-\nsurgery.\nAlthough significant efforts were made to conduct a\ncomprehensive and precise search within scientific\ndatabases, there remains a possibility that some\nrelevant studies were overlooked due to constraints\nsuch as limited resource accessibility, the selection of\nspecific search terms, or the restricted publication of\ncertain articles. Furthermore, while study quality was\nassessed using established and validated tools, the\npotential for human error in scoring or interpreting\nevaluation criteria cannot be entirely excluded. These\nlimitations may affect the outcomes despite diligent\nattempts to minimize biases.\n5.1. Conclusions\nTwo critical considerations in selecting the treatment\napproach for women with DIE are the recurrence and\npregnancy rates following treatment. Recurrence after\nDIE treatment has a significant negative impact on\nwomen's quality of life. Therefore, efforts should focus\non improving their quality of life by selecting the most\neffective treatment approach.\nIn this study, the overall recurrence rate for DIE\nfollowing various surgical approaches was reported to\nbe approximately 13%, while the pregnancy rate was 47%.\nThese findings provide valuable insights for choosing\nthe best treatment method for women who are suitable\ncandidates for surgery. However, due to the diversity of\nsurgical methods used and the limited number of cases\nfor each method, further studies with larger sample\nsizes and varied designs are needed. These future\nstudies would enable more informed decisions in this\nfield.\nAcknowledgem ents\nThe authors sincerely acknowledge Alborz University\nof Medical Sciences.\nFootnotes\nAuthors' Contribution: F. A. and F. A. R.: conceived,\ndesigned, and wrote the paper. All of the authors\nreviewed and interpreted the data.\nConflict of Interests Statem ent: We declare that one\nof our authors (Fatemeh Abdi) is of the reviewer in this\njournal. The journal confirmed that the author with CoI\nwas excluded from all review processes. During the\npreparation of this work the author(s) used [Free AI\nParaphrasing Tool] to [paraphrase]. After using this\ntool/service, the author(s) reviewed and edited the\ncontent as needed and take(s) full responsibility for the\ncontent of the publication.\nData Availability: The datasets used and/or analyzed\nduring the current study are available from the\ncorresponding author upon reasonable request.\nEthical Approval: This study was approved by the\nethical code IR.ABZUMS.REC.1401.025 at Alborz\nUniversity of Medical Sciences.\nFunding/Support: The current study did not receive\nany funding/support.\nReferences\n1. Saunders PTK, Horne AW. Endometriosis: Etiology, pathobiology, and\ntherapeutic prospects. Cell. 2021;184(11):2807-24. [PubMed ID:\n34048704]. https://doi.org/10.1016/j.cell.2021.04.041.\n2. Moradi Y, Shams-Beyranvand M, Khateri S, Gharahjeh S, Tehrani S,\nVarse F, et al. A systematic review on the prevalence of endometriosis\nin women. Indian J M ed Res. 2021;154(3):446-54. [PubMed ID:\n35345070]. [PubMed Central ID: PMC9131783].\nhttps://doi.org/10.4103/ijmr.IJMR_817_18.\n3. Meuleman C, Tomassetti C, D'Hoore A, Van Cleynenbreugel B,\nPenninckx F, Vergote I, et al. Surgical treatment of deeply infiltrating\nendometriosis with colorectal involvement. Hum  Reprod Update.\n2011;17(3):311-26. [PubMed ID: 21233128].\nhttps://doi.org/10.1093/humupd/dmq057.\n4. Li XY, Chao XP, Leng JH, Zhang W, Zhang JJ, Dai Y, et al. Risk factors for\npostoperative recurrence of ovarian endometriosis: long-term\nfollow-up of 358 women. J Ovarian Res. 2019;12(1):79. [PubMed ID:\n31470880]. [PubMed Central ID: PMC6717364].\nhttps://doi.org/10.1186/s13048-019-0552-y.\n5. Vercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, Crosignani PG.\nReproductive performance, pain recurrence and disease relapse\nafter conservative surgical treatment for endometriosis: the\npredictive value of the current classification system. Hum  Reprod.\n2006;21(10):2679-85. [PubMed ID: 16790608].\nhttps://doi.org/10.1093/humrep/del230.\n6. Vercellini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Crosignani PG.\nComparison of a levonorgestrel-releasing intrauterine device versus\nexpectant management after conservative surgery for symptomatic\n\nAbdi F et al. Brieflands\n12 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nendometriosis: a pilot study. Fertil Steril. 2003;80(2):305-9. [PubMed\nID: 12909492]. https://doi.org/10.1016/s0015-0282(03)00608-3.\n7. Ceccaroni M, Bounous VE, Clarizia R, Mautone D, Mabrouk M.\nRecurrent endometriosis: a battle against an unknown enemy. Eur J\nContracept Reprod Health Care. 2019;24(6):464-74. [PubMed ID:\n31550940]. https://doi.org/10.1080/13625187.2019.1662391.\n8. Olive DL, Pritts EA. Treatment of endometriosis. N Engl J M ed.\n2001;345(4):266-75. [PubMed ID: 11474666].\nhttps://doi.org/10.1056/NEJM200107263450407.\n9. Hernandez Gutierrez A, Spagnolo E, Zapardiel I, Garcia-Abadillo\nSeivane R, Lopez Carrasco A, Salas Bolivar P, et al. Post-operative\ncomplications and recurrence rate after treatment of bowel\nendometriosis: Comparison of three techniques. Eur J Obstet Gynecol\nReprod Biol X. 2019;4:100083. [PubMed ID: 31517307]. [PubMed Central\nID: PMC6728789]. https://doi.org/10.1016/j.eurox.2019.100083.\n10. Taylor E, Williams C. Surgical treatment of endometriosis: location\nand patterns of disease at reoperation. Fertil Steril. 2010;93(1):57-61.\n[PubMed ID: 19006792].\nhttps://doi.org/10.1016/j.fertnstert.2008.09.085.\n11. Ruffo G, Scopelliti F, Manzoni A, Sartori A, Rossini R, Ceccaroni M, et\nal. Long-term outcome after laparoscopic bowel resections for deep\ninfiltrating endometriosis: a single-center experience after 900\ncases. Biom ed Res Int. 2014;2014:463058. [PubMed ID: 24877097].\n[PubMed Central ID: PMC4022010].\nhttps://doi.org/10.1155/2014/463058.\n12. Ianieri MM, Mautone D, Ceccaroni M. Recurrence in Deep Infiltrating\nEndometriosis: A Systematic Review of the Literature. J M inim  Invasive\nGynecol. 2018;25(5):786-93. [PubMed ID: 29357317].\nhttps://doi.org/10.1016/j.jmig.2017.12.025.\n13. Kalaitzopoulos DR, Samartzis N, Kolovos GN, Mareti E, Samartzis EP,\nEberhard M, et al. Treatment of endometriosis: a review with\ncomparison of 8 guidelines. BM C W om ens Health. 2021;21(1):397.\n[PubMed ID: 34844587]. [PubMed Central ID: PMC8628449].\nhttps://doi.org/10.1186/s12905-021-01545-5.\n14. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow\nCD, et al. The PRISMA 2020 statement: An updated guideline for\nreporting systematic reviews. Int J Surg. 2021;88:105906. [PubMed ID:\n33789826]. https://doi.org/10.1016/j.ijsu.2021.105906.\n15. Missori G, Bonaduce I, Ricciardolo AA, Marchesini N, Alboni C,\nVarliero F, et al. Minimally-invasive multidisciplinary treatment of\ndeep endometriosis: 103 cases. Laparoscopic Surgery. 2024;8:3.\nhttps://doi.org/10.21037/ls-24-2.\n16. Han J, Zheng L. Analysis of Risk Factors for Bleeding and Recurrence\nof Ovarian Endometriomas after Laparoscopic Surgery and Its\nImpact on Pregnancy Outcomes. Clin Experim ental Obstetrics Gynecol.\n2024;51(1). https://doi.org/10.31083/j.ceog5101005.\n17. Zhang S, Yu H, Dong Z, Chen Y, Shan W, Zhang W, et al.\nLaparoendoscopic single-site surgery for deep infiltrating\nendometriosis based on retroperitoneal pelvic spaces anatomy: a\nretrospective study. Sci Rep. 2023;13(1):10785. [PubMed ID: 37402839].\n[PubMed Central ID: PMC10319708]. https://doi.org/10.1038/s41598-\n023-38034-8.\n18. Yang X, Bao M, Hang T, Sun W, Liu Y, Yang Y, et al. Status and related\nfactors of postoperative recurrence of ovarian endometriosis: a\ncross-sectional study of 874 cases. Arch Gynecol Obstet.\n2023;307(5):1495-501. [PubMed ID: 36708425]. [PubMed Central ID:\nPMC10110635]. https://doi.org/10.1007/s00404-023-06932-x.\n19. Leborne P, Huberlant S, Masia F, de Tayrac R, Letouzey V, Allegre L.\nClinical outcomes following surgical management of deep\ninfiltrating endometriosis. Sci Rep. 2022;12(1):21800. [PubMed ID:\n36526707]. [PubMed Central ID: PMC9758215].\nhttps://doi.org/10.1038/s41598-022-25751-9.\n20. Zhang N, Sun S, Zheng Y, Yi X, Qiu J, Zhang X, et al. Reproductive and\npostsurgical outcomes of infertile women with deep infiltrating\nendometriosis. BM C W om ens Health. 2022;22(1):83. [PubMed ID:\n35313876]. [PubMed Central ID: PMC8939234].\nhttps://doi.org/10.1186/s12905-022-01666-5.\n21. Kim SJ, Choi SH, Won S, Shim S, Lee N, Kim M, et al. Cumulative\nRecurrence Rate and Risk Factors for Recurrent Abdominal Wall\nEndometriosis after Surgical Treatment in a Single Institution. Yonsei\nM ed J. 2022;63(5):446-51. [PubMed ID: 35512747]. [PubMed Central ID:\nPMC9086694]. https://doi.org/10.3349/ymj.2022.63.5.446.\n22. Roman H, Huet E, Bridoux V, Khalil H, Hennetier C, Bubenheim M, et\nal. Long-term Outcomes Following Surgical Management of Rectal\nEndometriosis: Seven-year Follow-up of Patients Enrolled in a\nRandomized Trial. J M inim  Invasive Gynecol. 2022;29(6):767-75.\n[PubMed ID: 35181523]. https://doi.org/10.1016/j.jmig.2022.02.007.\n23. Ceccaroni M, Clarizia R, Mussi EA, Stepniewska AK, De Mitri P,\nCeccarello M, et al. “The Sword in the Stone”: radical excision of deep\ninfiltrating endometriosis with bowel shaving—a single-centre\nexperience on 703 consecutive patients. Surgical Endoscopy. 2022:1-14.\n24. Sarbazi F, Akbari E, Karimi A, Nouri B, Noori Ardebili SH. The Clinical\nOutcome of Laparoscopic Surgery for Endometriosis on Pain,\nOvarian Reserve, and Cancer Antigen 125 (CA-125): A Cohort Study. Int J\nFertil Steril. 2021;15(4):275-9. [PubMed ID: 34913296]. [PubMed Central\nID: PMC8530215]. https://doi.org/10.22074/IJFS.2021.137035.1018.\n25. Yela DA, Vitale SG, Vizotto MP, Benetti-Pinto CL. Risk factors for\nrecurrence of deep infiltrating endometriosis after surgical\ntreatment. J Obstet Gynaecol Res. 2021;47(8):2713-9. [PubMed ID:\n33998109]. https://doi.org/10.1111/jog.14837.\n26. Vidal F, Guerby P, Simon C, Lesourd F, Cartron G, Parinaud J, et al.\nSpontaneous pregnancy rate following surgery for deep infiltrating\nendometriosis in infertile women: The impact of the learning curve.\nJ Gynecol Obstet Hum  Reprod. 2021;50(1):101942. [PubMed ID:\n33049364]. https://doi.org/10.1016/j.jogoh.2020.101942.\n27. Parra RS, Feitosa MR, Camargo HP, Valerio FP, Zanardi JVC, Rocha J, et\nal. The impact of laparoscopic surgery on the symptoms and\nwellbeing of patients with deep infiltrating endometriosis and\nbowel involvement. J Psychosom  Obstet Gynaecol. 2021;42(1):75-80.\n[PubMed ID: 32538257].\nhttps://doi.org/10.1080/0167482X.2020.1773785.\n28. Jayot A, Bendifallah S, Abo C, Arfi A, Owen C, Darai E. Feasibility,\nComplications, and Recurrence after Discoid Resection for\nColorectal Endometriosis: A Series of 93 Cases. J M inim  Invasive\nGynecol. 2020;27(1):212-9. [PubMed ID: 31326634].\nhttps://doi.org/10.1016/j.jmig.2019.07.011.\n29. Abesadze E, Chiantera V, Sehouli J, Mechsner S. Post-operative\nmanagement and follow-up of surgical treatment in the case of\nrectovaginal and retrocervical endometriosis. Arch Gynecol Obstet.\n2020;302(4):957-67. [PubMed ID: 32661754]. [PubMed Central ID:\nPMC7471187]. https://doi.org/10.1007/s00404-020-05686-0.\n30. Ceccaroni M, Clarizia R, Ceccarello M, De Mitri P, Roviglione G,\nMautone D, et al. Total laparoscopic bladder resection in the\nmanagement of deep endometriosis: \"take it or leave it.\" Radicality\nversus persistence. Int Urogynecol J. 2020;31(8):1683-90. [PubMed ID:\n31494691]. https://doi.org/10.1007/s00192-019-04107-4.\n31. Abesadze E, Sehouli J, Mechsner S, Chiantera V. Possible Role of the\nPosterior Compartment Peritonectomy, as a Part of the Complex\nSurgery, Regarding Recurrence Rate, Improvement of Symptoms and\nFertility Rate in Patients with Endometriosis, Long-Term Follow-Up. J\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 13\nM inim  Invasive Gynecol. 2020;27(5):1103-11. [PubMed ID: 31449906].\nhttps://doi.org/10.1016/j.jmig.2019.08.019.\n32. Sun TT, Chen SK, Li XY, Zhang JJ, Dai Y, Shi JH, et al. Fertility Outcomes\nAfter Laparoscopic Cystectomy in Infertile Patients with Stage III-IV\nEndometriosis: a Cohort with 6-10 years of Follow-up. Adv Ther.\n2020;37(5):2159-68. [PubMed ID: 32200536].\nhttps://doi.org/10.1007/s12325-020-01299-w.\n33. Nirgianakis K, Ma L, McKinnon B, Mueller MD. Recurrence Patterns\nafter Surgery in Patients with Different Endometriosis Subtypes: A\nLong-Term Hospital-Based Cohort Study. J Clin M ed. 2020;9(2).\n[PubMed ID: 32054117]. [PubMed Central ID: PMC7073694].\nhttps://doi.org/10.3390/jcm9020496.\n34. Ceccaroni M, Ceccarello M, Caleffi G, Clarizia R, Scarperi S, Pastorello\nM, et al. Total Laparoscopic Ureteroneocystostomy for Ureteral\nEndometriosis: A Single-Center Experience of 160 Consecutive\nPatients. J M inim  Invasive Gynecol. 2019;26(1):78-86. [PubMed ID:\n29656149]. https://doi.org/10.1016/j.jmig.2018.03.031.\n35. Zheng Y, Cheng Q, Chang K, Ruan J, Tian Q, Gu S, et al. Analysis of the\nPredictive Factors for the Recurrence of Deep Infiltrating\nEndometriosis: A 2-Year Prospective Study. Reproductive Dev M ed.\n2019;3(4):213-21. https://doi.org/10.4103/2096-2924.274543.\n36. Shaltout MF, Elsheikhah A, Maged AM, Elsherbini MM, Zaki SS, Dahab\nS, et al. A randomized controlled trial of a new technique for\nlaparoscopic management of ovarian endometriosis preventing\nrecurrence and keeping ovarian reserve. J Ovarian Res. 2019;12(1):66.\n[PubMed ID: 31325962]. [PubMed Central ID: PMC6642736].\nhttps://doi.org/10.1186/s13048-019-0542-0.\n37. Roman H, Tuech JJ, Huet E, Bridoux V, Khalil H, Hennetier C, et al.\nExcision versus colorectal resection in deep endometriosis\ninfiltrating the rectum: 5-year follow-up of patients enrolled in a\nrandomized controlled trial. Hum  Reprod. 2019;34(12):2362-71.\n[PubMed ID: 31820806]. [PubMed Central ID: PMC6936722].\nhttps://doi.org/10.1093/humrep/dez217.\n38. Roman H, Chanavaz-Lacheray I, Ballester M, Bendifallah S, Touleimat\nS, Tuech JJ, et al. High postoperative fertility rate following surgical\nmanagement of colorectal endometriosis. Hum  Reprod.\n2018;33(9):1669-76. [PubMed ID: 30052994]. [PubMed Central ID:\nPMC6112593]. https://doi.org/10.1093/humrep/dey146.\n39. Saavalainen L, Heikinheimo O, Tiitinen A, Harkki P. Deep infiltrating\nendometriosis affecting the urinary tract-surgical treatment and\nfertility outcomes in 2004-2013. Gynecol Surg. 2016;13(4):435-44.\n[PubMed ID: 28003801]. [PubMed Central ID: PMC5133280].\nhttps://doi.org/10.1007/s10397-016-0958-0.\n40. Roman H, Milles M, Vassilieff M, Resch B, Tuech JJ, Huet E, et al. Long-\nterm functional outcomes following colorectal resection versus\nshaving for rectal endometriosis. Am  J Obstet Gynecol. 2016;215(6):762\ne1-9. [PubMed ID: 27393269]. https://doi.org/10.1016/j.ajog.2016.06.055.\n41. Roman H, Hennetier C, Darwish B, Badescu A, Csanyi M, Aziz M, et al.\nBowel occult microscopic endometriosis in resection margins in\ndeep colorectal endometriosis specimens has no impact on short-\nterm postoperative outcomes. Fertil Steril. 2016;105(2):423-9 e7.\n[PubMed ID: 26474734].\nhttps://doi.org/10.1016/j.fertnstert.2015.09.030.\n42. Afors K, Centini G, Fernandes R, Murtada R, Zupi E, Akladios C, et al.\nSegmental and Discoid Resection are Preferential to Bowel Shaving\nfor Medium-Term Symptomatic Relief in Patients With Bowel\nEndometriosis. J M inim  Invasive Gynecol. 2016;23(7):1123-9. [PubMed\nID: 27544881]. https://doi.org/10.1016/j.jmig.2016.08.813.\n43. Cao Q, Lu F, Feng WW, Ding JX, Hua KQ. Comparison of complete and\nincomplete excision of deep infiltrating endometriosis. Int J Clin Exp\nM ed. 2015;8(11):21497-506. [PubMed ID: 26885098]. [PubMed Central\nID: PMC4723943].\n44. Collinet P, Leguevaque P, Neme RM, Cela V, Barton-Smith P, Hebert T,\net al. Robot-assisted laparoscopy for deep infiltrating endometriosis:\ninternational multicentric retrospective study. Surg Endosc.\n2014;28(8):2474-9. [PubMed ID: 24609708].\nhttps://doi.org/10.1007/s00464-014-3480-3.\n45. Uccella S, Cromi A, Casarin J, Bogani G, Pinelli C, Serati M, et al.\nLaparoscopy for ureteral endometriosis: surgical details, long-term\nfollow-up, and fertility outcomes. Fertil Steril. 2014;102(1):160-166 e2.\n[PubMed ID: 24842674].\nhttps://doi.org/10.1016/j.fertnstert.2014.03.055.\n46. Nirgianakis K, McKinnon B, Imboden S, Knabben L, Gloor B, Mueller\nMD. Laparoscopic management of bowel endometriosis: resection\nmargins as a predictor of recurrence. Acta Obstet Gynecol Scand.\n2014;93(12):1262-7. [PubMed ID: 25175300].\nhttps://doi.org/10.1111/aogs.12490.\n47. Nezhat C, Main J, Paka C, Nezhat A, Beygui RE. Multidisciplinary\ntreatment for thoracic and abdominopelvic endometriosis. JSLS.\n2014;18(3). [PubMed ID: 25392636]. [PubMed Central ID: PMC4154426].\nhttps://doi.org/10.4293/JSLS.2014.00312.\n48. Mangler M, Herbstleb J, Mechsner S, Bartley J, Schneider A, Kohler C.\nLong-term follow-up and recurrence rate after mesorectum-sparing\nbowel resection among women with rectovaginal endometriosis. Int\nJ Gynaecol Obstet. 2014;125(3):266-9. [PubMed ID: 24726619].\nhttps://doi.org/10.1016/j.ijgo.2013.12.010.\n49. Neme RM, Schraibman V, Okazaki S, Maccapani G, Chen WJ, Domit\nCD, et al. Deep infiltrating colorectal endometriosis treated with\nrobotic-assisted rectosigmoidectomy. JSLS. 2013;17(2):227-34. [PubMed\nID: 23925016]. [PubMed Central ID: PMC3771789].\nhttps://doi.org/10.4293/108680813X13693422521836.\n50. Schonman R, Dotan Z, Weintraub AY, Goldenberg M, Seidman DS,\nSchiff E, et al. Long-term follow-up after ureteral reimplantation in\npatients with severe deep infiltrating endometriosis. Eur J Obstet\nGynecol Reprod Biol. 2013;171(1):146-9. [PubMed ID: 24017962].\nhttps://doi.org/10.1016/j.ejogrb.2013.08.027.\n51. Mabrouk M, Spagnolo E, Raimondo D, D'Errico A, Caprara G, Malvi D,\net al. Segmental bowel resection for colorectal endometriosis: is\nthere a correlation between histological pattern and clinical\noutcomes? Hum  Reprod. 2012;27(5):1314-9. [PubMed ID: 22416007].\nhttps://doi.org/10.1093/humrep/des048.\n52. Koh CE, Juszczyk K, Cooper MJ, Solomon MJ. Management of deeply\ninfiltrating endometriosis involving the rectum. Dis Colon Rectum.\n2012;55(9):925-31. [PubMed ID: 22874598].\nhttps://doi.org/10.1097/DCR.0b013e31825f3092.\n53. Jelenc F, Ribic-Pucelj M, Juvan R, Kobal B, Sinkovec J, Salamun V.\nLaparoscopic rectal resection of deep infiltrating endometriosis. J\nLaparoendosc Adv Surg Tech A. 2012;22(1):66-9. [PubMed ID: 22166117].\nhttps://doi.org/10.1089/lap.2011.0307.\n54. Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P,\net al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for\ninformation professionals and researchers. Education for Inform ation.\n2018;34(4):285-91. https://doi.org/10.3233/efi-180221.\n55. Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a\ntool for appraising the quality of qualitative, quantitative and mixed\nmethods studies, the Mixed Methods Appraisal Tool (MMAT). J Eval\nClin Pract. 2018;24(3):459-67. [PubMed ID: 29464873].\nhttps://doi.org/10.1111/jep.12884.\n56. Hox JJ, De Leeuw ED. Multilevel models for meta-analysis. In: De\nLeeuw ED, editor. M ultilevel m odeling. United Kingdom: Psychology\n\nAbdi F et al. Brieflands\n14 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nPress; 2003. p. 87-104.\n57. Huedo-Medina TB, Sanchez-Meca J, Marin-Martinez F, Botella J.\nAssessing heterogeneity in meta-analysis: Q statistic or I2 index?\nPsychol M ethods. 2006;11(2):193-206. [PubMed ID: 16784338].\nhttps://doi.org/10.1037/1082-989X.11.2.193.\n58. Rothstein HR, Sutton AJ, Borenstein M. Publication Bias in Meta ‐\nAnalysis. In: Rothstein HR, Sutton AJ, Borenstein M, editors.\nPublication Bias in M eta ‐ Analysis. Hoboken, New Jersey: Wiley; 2005. p.\n1-7. https://doi.org/10.1002/0470870168.ch1.\n59. Hedges LV, Olkin I. Statistical M ethods for M eta-Analysis. Cambridge,\nMassachusetts: Academic Press; 2014.\n60. Ferrero S, Roberti Maggiore UL, Biscaldi E, Altieri M, Vellone VG,\nStabilini C, et al. Bowel Occult Microscopic Endometriosis in\nResection Margins in Deep Colorectal Endometriosis Specimens Has\nNo Impact on the Long-Term Risk of Recurrence. Fertility Sterility.\n2020;114(3). https://doi.org/10.1016/j.fertnstert.2020.08.579.\n61. Bendifallah S, Vesale E, Darai E, Thomassin-Naggara I, Bazot M, Tuech\nJJ, et al. Recurrence after Surgery for Colorectal Endometriosis: A\nSystematic Review and Meta-analysis. J M inim  Invasive Gynecol.\n2020;27(2):441-451 e2. [PubMed ID: 31785416].\nhttps://doi.org/10.1016/j.jmig.2019.09.791.\n62. Rizk B, Fischer AS, Lotfy HA, Turki R, Zahed HA, Malik R, et al.\nRecurrence of endometriosis after hysterectomy. Facts Views Vis\nObgyn. 2014;6(4):219-27. [PubMed ID: 25593697]. [PubMed Central ID:\nPMC4286861].\n63. Bedaiwy MA, Pope R, Henry D, Zanotti K, Mahajan S, Hurd W, et al.\nStandardization of laparoscopic pelvic examination: a proposal of a\nnovel system. M inim  Invasive Surg. 2013;2013:153235. [PubMed ID:\n24490066]. [PubMed Central ID: PMC3892934].\nhttps://doi.org/10.1155/2013/153235.\n64. Guo SW. Recurrence of endometriosis and its control. Hum  Reprod\nUpdate. 2009;15(4):441-61. [PubMed ID: 19279046].\nhttps://doi.org/10.1093/humupd/dmp007.\n65. Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA.\nIncidence of symptom recurrence after hysterectomy for\nendometriosis. Fertil Steril. 1995;64(5):898-902. [PubMed ID: 7589631].\nhttps://doi.org/10.1016/s0015-0282(16)57899-6.\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 15\nTable 1. Key Findings of the 41 Studies Included in the Systematic Review\nID Author Year Country Design Num ber of\nParticipants Age (y) BMI\n(kg/m 2) Sym ptom s Location of\nEndom etriosis\nSurgical\nTechniques\nFollow-\nup\n(Months)\n1 Missori, et\nal. (15) 2024 Spain Cohort 103 36.55 (23 -\n50)\n24.66(15.90\n- 33.59)\nDyspareunia; dysmenorrhea;\nchronic pelvic pain;\ndyschezia; stranguria;\nabdominal distension;\ntenesmus; constipation;\ndiarrhea; hematochezia\nIntestine\nBowel resection\n(sigmoid-rectum\nresection, rectal\nshaving, discoid\nresection, ileal\nresection,\nstrictureplasty)\n27.52 (1 -\n54)\n2 Han and\nZheng (16) 2024 China Cohort 212 28.90 ±\n6.010\n23.03 ±\n3.625 Severe dysmenorrhea Ovaries Laparoscopic\nsurgery 24\n3 Zhang, et\nal. (17) 2023 China Cohort 63 31.25 ±\n5.81 22.62 ± 2.79\nPain; urinary symptoms;\ngastrointestinal symptoms;\ninfertility; adenomyosis\nPelvis\nTransumbilical\nsingle-port\nlaparoscopy\n22.90 ±\n5.46\n4 Yang, et al.\n(18) 2023 China Cross-\nsectional 347 35.18 ±\n6.187\nNot\nmentionedDysmenorrhea; Adenomyosis Ovaries Not mentioned 1 - 60\n5 Leborne,\net al. (19) 2022 France Cohort 165\n34.00\n(IQR:\n11.00)\n23.00 (IQR:\n6.00)\nDysmenorrhea; dyspareunia;\npain when defecating\nUterus, ovaries,\nfallopian tube,\npelvis\nperitoneum,\nvagina, recto\nvaginal wall,\nbowel and\ncutaneous scar\nSurgical excision 1.5\n6 Zhang et\nal. (20) 2022 China Cohort 34 30.22 ±\n3.62\nNot\nmentioned\nPrimary or secondary\ninfertility Ovaries\nMinimally\ninvasive surgical\ntechniques\n26.57  ±  \n14.51\n7 Kim et al.\n(21) 2022 South\nkorea Cohort 56 36.4 ± 5.7 21.9 ± 4.6\nPalpable abdominal mass\nwith increasing in size during\nprevious year\n55.6% C/S scar;\n-5.6% episiotomy\nsite; -16.7%\ninguinal area;\n-22.2%\nlaparoscopic\ntrocar site\n(including\numbilicus)\nLocal excision ; in\nmetastatic cases\nlaparoscopic\nhysterectomy\nwith bilateral\nsalpingo-\noophorectomy\nwith pelvic lymph\nnode dissection\n31.8 ± 26.9\n8 Roman et\nal. (22) 2022 France Cohort 55 27 - 36 Not\nmentioned\nDysmenorrhea; deep\ndyspareunia; pelvic pain\noutside periods\nRectum\nSegmental\nresection; nodule\nexcision via\nshaving or disk\nexcision\n84\n9 Ceccaroni,\net al. (23) 2022 Italy Cohort 703\nMedian:\n36 years\n(range: 21\n- 56)\n22.7 ± 4.9\nChronic pelvic pain;\ndysmenorrhea; dysuria;\ndyspareunia; dyschezia\nBowel\nLaparoscopic\nbowel shaving\nwith concomitant\nradical excision of\nDIE\nMedian:\n14 months\n(range: 6 -\n49)\n10 Sarbazi, et\nal. (24) 2021 Iran Cohort 174 34.86 ±\n6.47 24.95 ± 4.40\nMenorrhagiaMetrorrhagia;\ndysmenorrhea; dyspareunia;\nirregular menstruation;\ninfertility\nOvarian fossa and\nvaginal vault\nLaparo¬scopic\nsurgery 48\n11 Yela, et al.\n(25) 2021 Brazil Cohort 72 39.7 ± 6.3 26.9 ± 5.0\nDysmenorrhea; dyspareunia;\nchronic pelvic pain;\ndyschezia; dysuria; infertility\nIntestinal tract,\nurinary tract,\novaries,\nuterine/bladder\npouch, douglas\npouch\nSurgical\ntreatment to\nremove\nendometriosis\nlesions\n4.56 ±\n2.60 years\n12 Vidal, et\nal. (26) 2021 France Cohort\n50 (early\ngroup = 25 &\nlate group\n=25)\nEarly\ngroup:\n31.7 ± 3.9\n& late\ngroup :\n34.0 ± 3.5\nEarly\ngroup: 24.0\n± 4.3 & late\ngroup : 22.6\n± 3.5\nInfertility; pelvic pain;\ndysmenorrhea; dyspareunia;\npain on defecation; urinary\nsymptoms\nBowel\nLaparoscopic\nremoval of deep\nendometriosis\nlesions\n34.1\n13 Parra, et\nal. (27) 2021 Brazil Cross-\nsectional 77 36.4 ± 5.5\n25.7 kg/m2\n(min-\nmax:17.9 -\n37.5)\nInfertility; dyspareunia;\ndysmenorrhea adenomyosis Bowel\nLaparoscopic\ndiscoid resection,\nsegmental\nresection, or\nshaving of DIE\n2.3 years\n(6 mo-6.5\nyears)\n14 Jayot, et al.\n(28) 2021 France Cross-\nsectional 93\n34\n(range:19\n- 59)\n23 (range:17\n- 37)\nDysmenorrhea; dyspareunia\nchronic pelvic pain; dyschezia\npainful defecation infertility\nColorectal Discoid colorectal\nresection 20\n\nAbdi F et al. Brieflands\n16 Middle East J Rehabil Health Stud. 2025; 12(1): e151847\nID Author Year Country Design Num ber of\nParticipants Age (y) BMI\n(kg/m 2) Sym ptom s Location of\nEndom etriosis Surgical Techniques\nFollow-\nup\n(Months)\n15 Abesadze, et\nal. (29) 2020 Germany Cohort 15 RVE: 34 ± 5.4;\nRCE: 31 ± 4.8\nNot\nmentioned\nCyclic pelvic pain;\nchronic pelvic pain;\ndyspareunia;\ndyschezia; dysuria;\ninfertility\nRVE & RCE\nSingle laparoscopy\nwas performed in RCE\npatients & vaginal\nassisted laparoscopy\nin RVE patients\n36\n16 Ceccaroni,\net al. (30) 2020 Italy Cohort 264 36.8 ± 5.6 21.03 ± 3.26\nUrinary frequency;\ntenesmus;\nhematuria;\ndysmenorrhea; pelvic\npain; dyspareunia;\ndysuria;\ndyscheziacyclic\nsciatica and/or\npudendal/anogenital;\npain; infertility\nBladder\nLaparoscopic bladder\nresection with\nconcomitant radical\nexcision of DIE\n1; 6; 12\n17 Abesadze, et\nal. (31) 2020 Germany Cohort 54 35 ± 7 Not\nmentioned\nDysmenorrhea,\ndysuria, dyschezie,\ndyspareunia, chronic\npelvic pain, cyclical\npelvic pain, infertility\nPosterior\ncompartment\nof the\nperitoneum\nComplete excision > 60\n18 Sun, et al.\n(32) 2020 China Cohort 59 31.8 ± 3.6 21.4 ± 2.3\nInfertility\ndysmenorrhea;\nchronic pelvic pain\nOvaries Laparoscopic excision 60; 72\n19 Nirgianakis,\net al. (33) 2020SwitzerlandCohort 54 30.1 ± 5.0 23\nInfertility; dysuria or\nurinary urgency;\ndyschezia; deep\ndyspareunia;\ndysmenorrhea or\npelvic pain\nRectovaginal\nseptum\nLaparoscopic\nsegmental bowel\nresection\n36\n20 Ceccaroni,\net al. (34) 2019 Italy Cohort 160 36.1 22.1\nDysmenorrhea,\ndysuria, dyspareunia,\nand dyschezia\nUreteral,\nparametrial,\nand bowel\nLaparoscopic\nureteroneocystostomy 1 -6 - 12\n21 Zheng, et al.\n(35) 2019 China Cohort 11 35 (range: 20\n- 49)\n20.9 (range:\n16.2 - 27.9)\nInfertility,\ndysmenorrhea,\ndyspareunia ,rectal\nbleeding, tenesmus\npelvic pain, dyschezia\n, micturition,\nintermenstrual\nbleeding\nBowel Laparoscopic surgery 23.2\n22 Shaltout, et\nal. (36) 2019 Egypt RCT 200\nDrainage\nonly: 28.2 ±\n4.1;\ncystectomy\nonly: 26.6 ±\n4.4;\ndrainage &\nlaparoscopy:\n27.5 ± 3.7;\ncystectomy\n&\nlaparoscopy:\n27.9 ± 4.1\nDrainage\nonly: 25.5 ±\n1.3;\ncystectomy\nonly: 25.3 ±\n1.4; drainage\n&\nlaparoscopy:\n25.4 ± 1.3;\ncystectomy\n&\nlaparoscopy:\n25.3 ± 1.2\nInfertility; pelvic pain\nor pelvic mass\nunilateral &\nunilocular\nendometrioma\nOvaries Laparoscopic\napproaches 24\n23 Roman, et\nal. (37) 2019 France RCT\n55 (Excision\n:27,\nColorectal\nresection: 28\n)\nExcision :30\n(27 - 36)\nColorectal\nresection: 28\n(27 - 33)\nNR\nConstipation,\nfrequent bowel\nmovements, anal\nincontinence,\ndysuria, bladder\natony\nBowel Excision or Colorectal\nresection 24 - 60\n24\nHernandez\nGutierrez, et\nal. (9)\n2019 Spain Cohort 143\nI: Segmental\nresection:\n36.3 ± 5.6; II:\nDiscoid\nresection:\n34.9 ± 6.8;\nIII: Nodule\nshaving:\n36.6 ± 5.8\nSegmental\nresection:\n21.8 ± 0.7;\ndiscoid\nresection:\n21.05 ±1.2;\nnodule\nshaving: 21.6\n± 0.9\nDigestive symptoms Ileum, cecum,\nappendix\nSegmental resection;\ndiscoid resection;\nnodule shaving\n46.4 ± 0.5\nmonths\nfor the\ngroup I,\n42.2 ± 1.6\nmonths\nfor the\ngroup II,\n39.7 ± 1.8\nmonths\nfor the\ngroup III\n25 Roman, et\nal. (38) 2018 France RCT 36 28 (range: 23\n- 39)\n23.9 (range:\n17.3 - 33.1)\nDysmenorrhea,\ndyspareunia, chronic\nintermenstrual pelvic\npain, digestive\nsymptoms, urinary\nsymptoms, infertility\nRectaum\nConservative rectal\nsurgery over\nsegmental resection\n50 - 79\n26 Saavalainen,\net al. (39)\n2016 Finland Cohort 53 35.0 ± 4.4 23.1 ±3.7 Dysmenorrhea,\ndysuria, pollakisuria,\nand/or hematuria,\nUrinary tractLaparoscopic surgery 120\n\nAbdi F et al. Brieflands\nMiddle East J Rehabil Health Stud. 2025; 12(1): e151847 17\nID Author Year Country Design Num ber of\nParticipants Age (y) BMI (kg/m 2) Sym ptom s Location of\nEndom etriosis\nSurgical\nTechniques\nFollow-up\n(Months)\nresection:\n31.12 ± 4.5\nShaving:26.4\n± 3.4; discoid:\n24.1 ± 5.2;\nsegmental\nresection:27.3\n± 4.2\nDysmenorrhea;dyspareunia;\ndyschezia; infertility Bowel Shaving, discoid;\nsegmental resection 3 & 24\n30 Cao, et al.\n(43) 2015 China Cohort 93 34.99 ±\n7.15\nNot\nmentioned\nPelvic pain, bowel symptoms,\ndysmenorrhea, infertility\nCervical stump,\nvaginal stump,\npelvic sidewall,\nbladder, ureter,\nrectum, cul-de-\nsac,\nrectovaginal\nseptum,\nposterior fornix,\nuterosacral\nligaments\nLaparoscopic\ncomplete excision\n(n = 55), incomplete\nsurgeryof DIE (n =\n38)\n24\n31 Collinet, et\nal. (44) 2014 French Cohort 164 34.1 ± 7.3 24.4 ± 8.2\nDysmenorrhea, chronic pelvic\npain, dyspareunia,\nmenometrorrhagia , urinary\nfunctional signs , digestive\nfunctional signs, Infertility\nRectum,\nbladder, ureter,\nuterosacral\nligaments\nRobot-assisted\nlaparoscopy 10.2\n32 Uccella, et\nal. (45) 2014 Italy Cohort 109 35 (20 -\n54)\n21.5; (range:\n16.3 - 31.6)\nDysmenorrhea; pelvic pain;\ndyspareunia; dyschezia; lower\nback pain; urinary symptoms;\nhematuria\nUreter Laparoscopic\nureterolysis 15 - 109\n33 Ruffo, et al.\n(11) 2014 Italy Cohort 774 27.5 (22 -\n51)\n23.7 (18.5 -\n31.5)\nDyspareunia; constipation;\npelvic pain; diarrhea Bowel Laparoscopic bowel\nresections 54\n34 Nirgianaki,\net al. (46) 2014 SwitzerlandCohort 81 33 (24 -\n49) 22 (16 - 32)\nInfertility; dysuria or urinary\nurgency; dyschezia; deep\ndyspareunia; dysmenorrhea\nor pelvic pain\nBowel\nLaparoscopic\nsegmental bowel\nresection\n120\n35 Nezhat, et\nal. (47) 2014 USA Cohort 25\n37.7\n(range: 25\n- 60)\nNot\nmentioned\nChest complaint; Shoulder\npain; catamenial\npneumothorax; hemoptysis\nThoracic and\nabdominopelvic\nCombined video-\nassisted\nthoracoscopic\nsurgery and\ntraditional\nlaparoscopy\n9; 12\n36 Mangler, et\nal. (48) 2014 Germany Cohort 71\nMedian:\n33.35\n(range:\n24 - 39)\nMedian: 23\n(range: 17 - 31)\nDysmenorrhea;\nhypermenorrhea\ndyspareunia; chronic pelvic\npain defecating symptoms;\ndyschezia; hematochezia;\ncyclic rectal bleeding;\ndiarrhea and constipation;\ndysuria; back pain Infertility\nBowel Surgical nerve-\nsparing approach\nMedian:63.9\n(range: 6 -\n98)\n37 Neme, et\nal. (49) 2013 Brazil Cohort 10\nMedian\n:37\n(range:\n29 - 48)\nMedian : 23.5\n(range: 20 -\n26)\nPelvic\npain,Infertility,dysmenorrhea,\ndyspareunia,\ndyschezia,intestinal\ncramping, diarrhea, &\nconstipation\nColorectal\nRobotic-\nassistedlaparoscopic\ncolorectal resection\n12\n38 Schonman,\net al. (50) 2013 Israel Cohort 7 34.3 ± 5.5 Not\nmentioned\nDysmenorrhea, dyspareunia,\nflank pain (urinary\nsymptoms),\nUreter Ureteral\nreimplantation 42.3 - 20.0\n39 Mabrouk,\net al. (51) 2012 Italy Cohort 47\nMedian:\n34 (range\n: 25 - 39)\nMedian: 21\n(range: 17 -\n29)\nInfertility, tenesmus,\nabdominal distension, rectal\nbleeding, constipation,\ndiarrhoea, nausea and\nvomiting, pain on defecation,\ndysparaeunia, chronic pelvic\npain, dysmenorrhea\nColorectal Laparoscopic\nsegmental resection 18\n40 Koh, et al.\n(52) 2012 Australia Cohort 91\nMean: 35\n(range: 22\n- 46)\n24.1\nDysmenorrhea,menorrhagia,\ndyspareunia,infertility,\npelvic/low-back pain,\ndyschezia,\nurgency/diarrhea/tenesmus,\nrectal bleeding\nRectal\nDisc resection,\nSegmental\nresections\n120\n41 Jelenc, et\nal. (53) 2012 Slovenia Cohort 52\nMean:\n34.4\n(range: 22\n- 62)\nNot\nmentioned\nDysmenorrhea,\ndyspareunia,chronic pelvic\npain, infertility\nColorectal Laparoscopic disk\nresection 84\nAbbreviations: BMI, Body Mass Index; DIE, deep infiltrating endometriosis.","source_license":"CC0","license_restricted":false}