Surgical management of endometriosis: indications, patient preparation, and perioperative planning: Number 6 - 2026

Preoperative counseling for endometriosis surgery should be patient-centered and structured around shared decision making, integrating symptom burden, disease phenotype, impact on quality of life, and reproductive goals. Counseling must emphasize that surgery is not curative and that outcomes vary according to disease characteristics and individual patient factors. ( 1 , 16 , 20 , 21 ) Expected benefits of surgery include pain reduction, improvement in quality of life, restoration of pelvic anatomy, and potential enhancement of fertility in selected cases. Surgical treatment is most effective for deep infiltrating disease, large or symptomatic ovarian endometriomas, hormone-resistant pain, and cases associated with organ dysfunction. Benefits are less predictable for superficial peritoneal disease, and patients should be counseled accordingly. ( 1 – 5 , 9 , 20 , 38 ) Risks must be discussed transparently and include bleeding, infection, injury to pelvic organs, and loss of ovarian reserve, particularly after excision of ovarian endometriomas. Recurrence is common; longitudinal studies show pain recurrence rates of approximately 40–45%, with 15–20% of women requiring repeat surgery within two years and up to 50% undergoing reoperation within five to seven years. Persistent or recurrent pain is more frequent in women with centralized or multifactorial pain syndromes. ( 1 – 5 , 38 ) Postoperative recurrence risk and long-term management should be addressed preoperatively. For women not seeking immediate pregnancy, postoperative hormonal suppression with combined oral contraceptives, progestins, or levonorgestrel-releasing intrauterine systems is recommended to reduce recurrence and maintain symptom control. Long-term medical therapy after surgery is required for most patients. ( 2 , 10 , 21 , 35 , 37 ) Alternative treatment options should be clearly presented, including nonsteroidal anti-inflammatory drugs, hormonal therapies, and expectant management. Surgery should generally be reserved for women in whom medical therapy is ineffective, contraindicated, or not tolerated, or for those with deep disease or large endometriomas causing significant symptoms or organ compromise. In infertility, counseling must emphasize that surgery may improve spontaneous conception in selected cases but does not replace assisted reproductive technologies, which remain the most effective strategy for many patients. ( 2 , 4 , 5 , 10 , 20 , 21 ) Patients should also be informed about existing uncertainties, including limited high-quality comparative data on long-term pain relief, fertility outcomes, and quality-of-life benefits across disease phenotypes and surgical techniques. These uncertainties should be incorporated into counseling to support realistic expectations and informed consent. ( 2 , 9 , 21 , 38 ) Preoperative counseling should clearly communicate that surgery may improve symptoms and fertility in selected women but carries relevant risks, including recurrence and potential ovarian reserve loss. Long-term medical therapy is frequently required, and alternative medical and reproductive options must be discussed. Surgical decisions should be individualized and aligned with symptom severity, disease phenotype, quality of life, and reproductive goals. ( 1 – 5 , 9 , 10 , 16 , 20 , 21 , 35 , 37 , 38 )

Endometriosis is a chronic, heterogeneous disease in which surgical treatment should be selective and individualized. Symptom burden, disease phenotype, impact on quality of life, and reproductive goals are more relevant than disease stage in guiding surgical decision making. Surgery is not first-line therapy and offers limited benefit in women with mild symptoms or adequate response to medical treatment. Clear surgical benefit is more consistently observed in symptomatic ovarian endometriomas and deep infiltrating endometriosis associated with organ dysfunction. Preoperative assessment is critical to balance expected benefit against surgical risk, particularly regarding ovarian reserve and long-term morbidity. Surgery is not curative and should be framed as one component of a longitudinal management strategy, frequently requiring postoperative medical therapy. Complex disease phenotypes and fertility-preserving surgery benefit from specialized or multidisciplinary care.

Structured perioperative care pathways, including Enhanced Recovery After Surgery programs, play a central role in contemporary endometriosis surgery by reducing postoperative pain, accelerating recovery, and improving patient satisfaction across different disease phenotypes, including deep infiltrating and ovarian endometriosis. ( 39 – 49 ) Key ERAS components include multimodal opioid-sparing analgesia, early mobilization, early enteral feeding, shortened fasting with carbohydrate loading, avoidance of routine mechanical bowel preparation, and structured preoperative education. These measures are associated with significant reductions in opioid consumption, improved early pain control, faster gastrointestinal recovery, and shorter hospital stay. ( 40 – 43 , 47 ) Multimodal analgesia strategies reduce perioperative opioid use by up to 60%, with lower early postoperative pain scores. Early mobilization and feeding decrease postoperative ileus and shorten time to gastrointestinal recovery, while preoperative carbohydrate loading attenuates the surgical stress response and improves perioperative metabolic stability. ( 40 – 43 ) Structured patient education and expectation management are integral to recovery pathways and are associated with higher patient satisfaction, improved functional recovery, and increased rates of same-day or early discharge without higher complication or readmission rates. Preoperative counseling within ERAS frameworks should be viewed as a therapeutic intervention rather than a purely informational step. ( 40 , 44 , 45 , 48 ) In women undergoing surgery for deep infiltrating endometriosis, ERAS implementation reduces length of stay by approximately one to one and a half days and is associated with lower postoperative morbidity, even in complex procedures such as bowel resection. These protocols do not negatively affect fertility outcomes. Preservation of ovarian reserve depends primarily on surgical technique rather than perioperative pathways, although faster recovery may indirectly facilitate reproductive planning. ( 8 , 39 , 48 , 50 ) ERAS protocols should be adapted to disease complexity, symptom burden, and patient-specific factors, including chronic pelvic pain, centralized pain syndromes, and prior opioid use. Their impact on fertility is indirect and mediated through reduced morbidity and faster recovery rather than direct reproductive effects. ( 8 , 50 , 51 ) Structured perioperative care pathways, including ERAS programs, are an essential component of high-quality surgical management in endometriosis. When appropriately tailored and consistently applied, they improve recovery, reduce postoperative pain and opioid use, shorten hospitalization, and enhance patient-centered care without compromising reproductive outcomes. Implementation of ERAS pathways should be considered a quality benchmark in endometriosis surgery.

Endometriosis surgery should be referred to specialized or multidisciplinary centers when patients present with deep infiltrating disease, large or complex ovarian endometriomas, involvement of bowel, ureter, bladder, or thoracic structures, severe or refractory symptoms, organ dysfunction, or when fertility preservation is a priority in the context of anticipated high surgical complexity. ( 1 – 4 , 10 , 16 , 17 , 19 , 21 , 52 ) Referral is particularly indicated when first-line medical therapies are ineffective, not tolerated, or contraindicated, and in the presence of clinically relevant organ compromise, such as hydronephrosis, bowel obstruction, hematuria, or hematochezia, or when there is suspicion of malignancy. Contemporary international recommendations emphasize that referral decisions should be individualized and based on symptom burden, disease phenotype, imaging findings, and reproductive goals, within a shared decision-making framework. ( 1 , 2 , 4 , 10 , 16 , 17 , 19 ) Deep infiltrating endometriosis frequently involves complex anatomic sites, including the rectosigmoid colon, bladder, ureters, and, less commonly, thoracic structures. Large or atypical ovarian endometriomas, particularly those exceeding five centimeters, further increase surgical complexity and risk. These scenarios require advanced imaging, structured preoperative disease mapping, and high-level surgical expertise, as procedures may involve ureterolysis, bowel resection, or coordinated thoracic intervention, with potential implications for fertility and postoperative morbidity. ( 1 – 3 , 17 , 52 ) Evidence from observational cohorts and guideline-based recommendations supports management of complex endometriosis in high-volume centers with coordinated multidisciplinary teams. These teams typically include gynecologic surgeons with advanced minimally invasive expertise, colorectal surgeons, urologists, radiologists, anesthesiologists, and reproductive specialists when appropriate. Such an approach is associated with improved surgical completeness, lower complication rates, and better functional outcomes, particularly in patients with deep infiltrating disease and multi-organ involvement. ( 1 , 3 , 17 , 21 , 52 ) Disease phenotype and symptom severity should guide referral decisions. Deep infiltrating disease and large endometriomas are associated with longer operative times, higher complication risk, and increased likelihood of ovarian reserve impairment, reinforcing the importance of experienced teams and multidisciplinary planning. Fertility preservation considerations, including the risk of diminished ovarian reserve after endometrioma excision, should be explicitly discussed and incorporated into referral pathways and surgical strategy. ( 3 , 16 , 19 , 21 ) Quality-of-life impact and reproductive goals must be systematically assessed and integrated into surgical planning. Use of validated patient-reported outcome measures is encouraged to quantify symptom burden and support individualized care. Preoperative counseling should address expected benefits, recurrence risk, the potential need for postoperative medical therapy, and long-term implications for fertility, particularly in reproductive-age women undergoing complex ovarian or deep pelvic surgery. ( 1 – 3 , 16 , 17 ) Referral to specialized or multidisciplinary centers is recommended for women with deep infiltrating endometriosis, large or complex endometriomas, organ involvement, severe or refractory symptoms, or when fertility preservation is a priority in the context of high surgical complexity. This approach ensures access to advanced imaging, coordinated interdisciplinary care, and expertise in complex surgical techniques, optimizing outcomes while minimizing risks, in accordance with current international guideline-based recommendations and best clinical practice. ( 1 – 4 , 10 , 16 , 17 , 19 , 21 , 52 ) Certain clinical scenarios require referral to specialized or multidisciplinary centers in order to optimize outcomes, minimize morbidity, and appropriately address fertility preservation and organ-specific risks ( Table 1 ).

Women with mild or asymptomatic endometriosis, as well as those whose symptoms are adequately controlled with first-line hormonal therapies, are unlikely to benefit from surgical treatment and should generally be managed conservatively. In this population, surgery does not provide additional benefit in terms of pain control or quality of life and exposes patients to unnecessary operative risks. ( 2 – 4 , 10 ) Women who do not desire future fertility and who do not present severe pain, organ dysfunction, or large ovarian endometriomas can usually be managed effectively with long-term suppressive medical therapy. Continuous hormonal regimens, including combined oral contraceptives, progestin-only therapies, and intrauterine systems, provide sustained symptom relief and are preferred in the absence of clear surgical indications. ( 1 , 4 , 6 ) Conservative management is particularly appropriate for women with contraindications to surgery, increased surgical risk, or significant comorbidities, in whom the potential benefits of surgery are outweighed by the risks of perioperative complications, symptom recurrence, and cumulative harm, especially after repeated or extensive procedures that may further compromise ovarian reserve. ( 1 , 6 , 11 ) In women with centralized pain phenotypes, multisite pain, or persistent symptoms after prior surgery, further operative intervention rarely provides sustained benefit and may exacerbate pain chronicity. In these cases, treatment should shift toward a multimodal conservative strategy, including neuromodulation and other approaches targeting central pain mechanisms. ( 1 , 6 , 11 , 12 ) Current consensus supports a selective, symptom-focused approach, reserving surgery for women with refractory symptoms, organ dysfunction, or infertility not amenable to medical therapy. For the majority of women without these indications, long-term hormonal suppression and multidisciplinary pain management, including pelvic floor physiotherapy for assessment and treatment of associated myofascial dysfunction, remain the cornerstone of treatment. ( 1 , 4 , 6 , 11 , 13 , 14 )

Surgical decision making in endometriosis should be guided by an individualized clinical context, integrating symptom burden, disease phenotype, impact on quality of life, and reproductive goals, rather than being based primarily on disease stage. The revised American Society for Reproductive Medicine (rASRM) classification has limited ability to predict pain severity, response to treatment, or prognosis. Women with minimal disease may experience severe symptoms, whereas others with advanced disease may remain asymptomatic, underscoring the poor correlation between anatomic staging and clinical presentation. ( 3 , 18 ) Contemporary guidelines and reviews consistently discourage the use of disease stage alone to guide surgical indications. Surgery is primarily recommended for women with severe or refractory symptoms, organ dysfunction, or infertility not amenable to medical therapy, while routine surgical intervention is not indicated in asymptomatic women or in those with mild disease well controlled with medical treatment. ( 2 , 6 , 16 ) Disease phenotype provides more clinically relevant information than stage. Deep infiltrating endometriosis, large or suspicious ovarian endometriomas, and lesions associated with bowel, bladder, or ureteral involvement are more likely to benefit from surgical intervention. In parallel, patient priorities—including fertility goals, the potential risk of ovarian reserve loss, and the psychosocial impact of symptoms—must be central to shared decision making and transparent counseling regarding potential benefits and risks. ( 2 – 6 , 19 , 20 ) Despite advances in surgical techniques, important evidence gaps persist. High-quality data linking specific phenotypes and symptom profiles to optimal surgical outcomes remain limited, and current classification systems do not adequately capture disease complexity or predict long-term benefit. There is a clear need for improved phenotypic stratification and prospective studies focused on patient-centered outcomes. ( 14 , 17 , 18 , 21 ) Current consensus supports a selective, symptom-driven approach to surgery in endometriosis. Surgical intervention should be reserved for women with significant symptom burden, disease phenotypes associated with organ compromise or reproductive impairment, or substantial impact on quality of life, and should not be determined solely by disease stage. ( 2 , 3 , 6 , 14 , 16 – 22 )

Endometriosis is a chronic and heterogeneous disease associated with pelvic pain, infertility, and impaired quality of life. Surgical treatment is not first-line therapy and should be reserved for selected clinical scenarios in which medical management is ineffective, contraindicated, or inappropriate. Clear indications include persistent or severe pain refractory to optimized hormonal therapy, intolerance or contraindication to medical treatment, ovarian endometriomas with specific indications such as large size or suspicious imaging features, deep infiltrating disease associated with organ dysfunction, and selected cases of endometriosis-associated infertility in which anatomical correction may improve outcomes or when assisted reproduction is not preferred or feasible. ( 1 – 4 ) Disease phenotype and symptom burden are central to surgical decision making, as benefits and risks differ substantially among superficial peritoneal disease, ovarian endometriomas, and deep infiltrating endometriosis. ( 2 – 5 ) Patient priorities, particularly reproductive goals and impact on quality of life, must be explicitly integrated into the indication for surgery. ( 3 – 6 ) Preoperative assessment should include comprehensive clinical evaluation, structured imaging with transvaginal ultrasound and/or magnetic resonance imaging for disease mapping, and fertility assessment when relevant. ( 2 , 4 , 6 ) In complex cases, particularly deep infiltrating disease, multidisciplinary planning is recommended to optimize outcomes and minimize complications. ( 1 , 3 , 5 ) Because surgery is not curative and recurrence is common, counseling should address realistic expectations, potential impact on ovarian reserve, perioperative risks, and the likely need for postoperative medical therapy when pregnancy is not immediately desired. ( 1 , 2 , 4 ) This Position Statement defines the appropriate indications for surgical treatment of endometriosis and emphasizes selective, individualized decision making based on disease phenotype, symptom severity, quality of life, and reproductive goals. Figure 1 summarizes a structured, multidimensional preoperative framework designed to guide appropriate surgical indication and planning in women with endometriosis.

Surgical management of endometriosis requires a selective, individualized, and patient-centered approach. Surgery should be regarded as one component of a comprehensive and longitudinal treatment strategy rather than a definitive solution. Decisions regarding indication, timing, extent of surgery, and referral level must integrate symptom burden, disease phenotype, impact on quality of life, and reproductive goals, supported by structured imaging and multidisciplinary evaluation when appropriate. Transparent counseling and shared decision making are essential to align surgical objectives with patient expectations and to optimize long-term outcomes.

Surgical treatment should be considered only in women with clinically significant symptoms, organ dysfunction, or well-defined clinical indications. Women with mild symptoms or adequate control with medical therapy should be managed conservatively. Preoperative evaluation should include structured transvaginal ultrasound and pelvic MRI when deep disease is suspected, to guide surgical planning and counseling. Assessment of ovarian reserve should be considered before surgery in women with ovarian endometriomas and reproductive plans, particularly in cases of bilateral or repeat surgery. Patients should be counseled preoperatively regarding realistic expectations, recurrence risk, potential impact on fertility, and the role of long-term postoperative management. Structured perioperative care pathways, including Enhanced Recovery After Surgery (ERAS) protocols, should be implemented in endometriosis surgery to optimize postoperative recovery, reduce morbidity, and improve patient experience. Referral to specialized or multidisciplinary centers should be considered for deep infiltrating disease, complex ovarian endometriomas, or fertility-preserving surgery with anticipated high complexity.