Conservative Management versus Rectal Resection in Deep Infiltrating Endometriosis of the Rectum

► deep endometriosis ► conservative ► rectal resection

Background Rectal deep in filtrating endometriosis has become an increasing prob- lem with two main management strategies; radical surgery by segmental colorectal resection, and a conservative surgery that includes removal of the lesion with rectal conservation. Aim was to compare between conservative management of deep in filtrating endome- triosis of the rectum by shaving or disc excision and segmental radical colorectal resection regarding short term patients ’ outcome, digestive and urinary outcomes. Patients and methods: Included 60 patients with deep endometriosis in filtrating the rectum were randomly divided into 2 equal groups the first group underwent conservative surgery by either rectal shaving or disc excision and the second group underwent colorectal resection.

We showed that rectal stenosis was more in the group of patients who are managed by segmental resection (some of patients with secondary stenosis underwent secondary resection of colo-rectum and the others under general anesthe- sia had endoscopic dilatation. Risks of postoperative complication, as recto-vaginal fistula and dysfunction of the urinary bladder which required long term self-catheterization were more common in the patients who underwent segmental resection. Constipation is recorded in (11.1%) of the conservative group and in (9.1%) of the segmental resection group, frequent bowel movements is recorded in (8%) the conservative group and in 7 (22%) of the se gmental resection group, defecation pain is recorded in (19%) of the conservative group and in 6 (19%) the segmental resection group, and involuntary loss of gas or stools were recorded in (12%) the received April 26, 2025 accepted after revision November 10, 2025 DOI https://doi.org/ 10.1055/s-0045-1814452. ISSN 2237-9363. Editor-in-Chief :H e n r i q u e Fillmann. © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda., Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil THIEME Original Article 1 Article published online: 2026-05-20

Deep infiltrating endometriosis is the presence of infiltration by endometrial glands and stroma deeply in the sub-perito- neal regions or muscle layer of hollow organs forms 10% of deep endometriosis, which occurs in females in the child- bearing age. It is usually associated with the presence of ovarian endometriomas and peritoneal endometriosis. 1 Patients with such problems usually complain of; dysmenor- rhea, chronic pelvic pain, dyspareunia, primary or secondary infertility, urinary tract and gastrointestinal complaints which negatively affect life quality. 2 Deep in filtrating endometriosis is complicated by dense fibrosis, severe pelvic adhesions which results in normal anatomy distortion. Aim of management to carefully remove the lesions, restore normal anatomy, and promote preserve or restore fertility. 3 Rectal deep in filtrating endometriosis has become an in- creasing problem with two main management strategies 4; radical surgery by segmental colorectal resection, and a con- servative surgery that includes removal of the lesion with rectal conservation. 5 There are different conservation approaches as lesion shaving without opening the rectum, 6 a 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 rectum could be removed by full thickness resection or disc excision. 7 It was previously demonstrated that although radical surgical excision leads to a complete removal of all lesions but the conservative management with rectal pres- ervation improved the digestive functions. 8 There are many studies evaluated bene fits and drawbacks of one of the performed approaches. 9–11 But, there are no suf ficient data regarding comparative studies between both management strategies. Aim was to compare between conservative management of deep in filtrating endometriosis of the rectum by shaving or disc excision and segmental radical colorectal resection regarding short term patients ’ outcome, digestive and uri- nary outcomes. Patients and Methods In the present retrospective, comparative and randomized study we included patients with deep in filtrating rectal endometriosis in the period between March 2019 and Janu- ary 2023 we divided them according to management approaches into two groups the first group underwent conservative rectal surgery and the other group underwent segmental resection. Inclusion Criteria Patients aged from 20-40 years with clinical, endoscopic, sonographic and radiological MRI evidence of deep endome- triosois in filtrating the rectum about 2 cm length, up to 15 cm from anus, more than half of the thickness of the muscle layer of rectum and up to half of rectal circumference. We explained the study aim and principles to included patients and written informed consents were acquired from all patients to be included in the study. Approval to perform the study was acquired from institu- tional review board of Faculty of Medicine, Zagazig University. Included 60 patients were randomly divided into 2 equal groups the first group underwent conservative surgery by either rectal shaving or disc excision and the second group underwent colorectal resection. We collect all baseline data of patients as; demographic, urinary, gastrointestinal and pelvic manifestations. Surgical Procedures Management procedures of the conservative group of patients underwent surgical management of deep endome- triosis of the rectum by performing shaving or performing disc excision. We performed shaving of nodules by; ultrasound scalpel, scissors, or using plasma energy, 12 up to total excision of any grossly detected nodules. We opened deep sub-peritoneal space which is found between the rectum and uterosacral ligament longitudinally, to avoid hypo-gastric and splanch- nic nerves injury. We performed disc excision by using trans-anal stapler or by a direct approach through the vagina if it was opened for removing nodules in filtrating the vagina. 12 We started the process of disc excision by performing rectal shaving, as previously mentioned. Then if we found the area of rectum that is shaved was still in filtrated by the endometriotic nodules. Then we achieved full thickness excision of the disc, by transanal approach. Choosing to perform either shaving and/or disc excision depends on patient state and surgeon. 13 Management procedures of the radical group of patients underwent surgical management of in filtrating rectal endo- metriosis by performing segmental resection of the colo- conservative group and in (30%) in the segmental resection group. Spontaneous conception was recorded in (70%) and (60%) of patients in both groups respectively.

we showed a slightly better outcome of patient who underwent conser- vative surgery for deep in filtrating endometriosis of rectum management and it might improves functional digestive and urinary outcomes, in comparison to resection of colo-rectum. J Coloproctol Vol. 46 No. 1/2026 © 2026. The Author(s). Conservative vs. Rectal Surgery in Deep Endometriosis Eltaher etal.2 rectum, in addition to resection of different parts of colon or small bowel whenever indicated. 14–16 We have dissected through the recto-vaginal septum. Multidisciplinary team that was composed of gynecologic and general surgeons who were experienced in performing colorectal surgeries performed these surgical procedures. We assessed the patient in a postoperative visit about 6 – 12 weeks after performing the surgical procedure for assess- ing immediate postoperative outcome and management of any postoperative complications as assessed by Clavien – Dindo classi fication. 17 Outcomes After performing surgeries were followed patients at 6, 12, 18 and 24 month for assessment of digestive and urinary outcomes. Primary evaluated endpoints after surgery by about 24 months were; constipation (1 stool/ > 5 days), frequent bowel movements ( /C214 stools/day), pain during defecation, anal incontinence, dysuria or bladder atony, bladder voiding by self-catheterization. Secondary evaluated endpoints after surgery were; VAS, KESS, GIQLI, Wexner, USP, SF36 scores. Statistical Analysis Statistical analyses were carried out using SAS 9.3 software (Cary, NC). To compare between the 2 included groups regarding treatment strategies by detecting the presence of functional symptoms at certain time, we used Fisher ’s exact test for categorical characteristics, we used Wilcoxon ’s test. P-value was <0.05 was considered signi ficant.

We included 60 patients in our study then we randomly divided them into 2 groups the first group included 30 patients were managed by conservative surgery and the second group included 30 patients and was managed by segmental resection. There is statistically non-signi ficant difference between the studied groups regarding age, VAS score, GLIQI, Wexner score, preoperative symptoms, number of rectal nodule, largest diameter of rectal nodule, distance from anal verge or deepest in filtrating layer We analyzed included patients for the primary outcome. We detected multifocal rectal endometriosis in 50% of patients. In the first group of patients that are managed by conser- vative surgery underwent disc excision by Rouen technique, disc excision using a trans-anal end-to-end circular stapler and direct trans-vaginal disc excision. Assessment of Postoperative outcomes and compli- cations: We showed that stenosis of the rectum was more in the group of patients who are managed by segmental resection (some of patients with secondary stenosis underwent secondary colorectal resection and the others had endoscopic dilations under general anesthesia). Risks of postoperative complication, as recto-vaginal fis- tula and bladder dysfunction which required long term self- catheterization were more common in the patients who underwent segmental resection. There is statistically non-signi ficant difference between the studied groups regarding operative time, estimated blood loss, length of rectal segment, highest of colorectal anastomosis, or temporary stoma Functional post-operative digestive symptoms in includ- ed groups Constipation is recorded in (11.1%) of the conservative group and in (9.1%) of the segmental resection group, frequent bowel movements is recorded in (8%) the conser- vative group and in 7 (22%) of the segmental resection group, defecation pain is recorded in (19%) of the conservative group and in 6 (19%) the segmental resection group, and involuntary loss of gas or stools were recorded in (12%) the conservative group and in (30%) in the segmental resection group. As regards secondary outcomes, the values of KESS, GIQLI, Wexner, USP, SF36 and VAS scores were comparable between the two arms. There is statistically signi ficant decrease in VAS score of dysmenorrhea, dyspareunia, pelvic pain, dyschezia and Wex- ner incontinence score. There is statistically signi ficant in- crease in GLIQI score Which denoted better outcome During the follow-up period of 24 months patients in both included groups attempted pregnancy: (50%) in the conser- vative surgery group and in the segmental resection group (65%). Among them, (70%) and (50%) of them conceived during the follow-up respectively. Spontaneous conception was recorded in (70%) and (60%) of patients in both groups respectively. Spontaneous conception was recorded in (70%) and (60%) of patients in both groups respectively.

In the present study we compared between patients under- went conservative management and patients underwent segmental resection in deep infiltrating pelvic endometriosis which mainly in filtrates the rectum. We showed a slightly better outcome of patient who underwent conservative management than patient underwent de finitive segmental resection. Previous comparative reports showed variable results; some studies demonstrated better functional out- comes after performing conservative surgery. 10 Other stud- ies showed there were no statistically signi ficant differences between conservative surgery and de finitive surgical resec - tion regarding; functional, digestive and urinary symptoms. 4 Regarding immediate post-operative complications, we showed that there is a higher risk of occurrence of rectal stenosis in patients who underwent segmental colorectal resection and they required additional surgical or endoscop- ic intervention. In our study we included patients with only large endo- metrial nodules as most surgeons considered de finitive J Coloproctol Vol. 46 No. 1/2026 © 2026. The Author(s). Conservative vs. Rectal Surgery in Deep Endometriosis Eltaher etal. 3 surgical management by segmental resection is an overtreat- ment in management of small rectal nodules. Points of Strengths Inclusion of patients with nearly similar data, that were managed by quali fied surgeons. We carefully followed up and assessed all included patients for accurate results. Previous studies showed that during post-operative as- sessment of digestive functions, complete removal of deep infiltrating endometriosis of the rectum has no roles in relieving digestive symptoms. 18,19 Which is similar to our findings that bowel resection has no bene fits in improving bowel functions. Our findings are slightly different from findings of few previous studies that demonstrated improvement of post- operative digestive functional outcomes. But, these variable findings might be due to inclusion of patients with severe infiltrating endometriosis which were managed by resection of colorectum and patients with smaller nodules which were managed by nodules shaving. Deep infiltrating endometriotic nodules of rectum remov- al by disc excision or by shaving, lead to preservation of mesorectum and rectal neurovascular supply without mod- ifications in rectum overall length, but all these advantages might have no major positive effect on rectal function after the operation, in comparison with colorectal resection. 20,21 These findings might have many explanations; deep in fil- trating endometriosis of the rectum might also affect ute- rosacral ligaments, parametrium, vagina, inferior hypogastric plexus and also splanchnic nerves. Additionally complete local conservative resection of large in filtrating endometriotic nodules lead to postoperative dysfunction of vegetative nerves. 21–25 Furthermore, postoperative dysfunction of rectal or uri- nary bladder, 26 which were found to be irreversible and could not restored by nodules removal. Colorectal resection was priously demonstrated to be associated with higher risks of rectovaginal leakage and fistula in comparison to shaving. 27 Rates of pregnancy and postoperative spontaneous conceptions after 24 months in both groups were nearly similar. None of our patients showed any endometriosis recur- rence during the 24 months following the surgery. In conclusion, we showed a slightly better outcome of patient who underwent conservative surgical management of deep endometriosis in filtrating rectal wall and it might improves functional digestive and urinary outcomes, in comparison to radical resection of colon or rectum. More- over, surgical resection of colorectal endometriosis might be safely performed to young female patients with severe endometriosis and pregnancy intention, but it should be kept in mind that; resection of the colorectum is responsible for a higher rate of bowel stenosis that might require redo procedures, under general anesthesia. Finally patients should be informed that there is a risk of abnormal bowel movements in 40% of cases regardless of surgical management. Recommendations As recurrence of endometriosis might happen after 2 years, we recommend performing a large scale study included larger number of cases with a follow-up period of more than 2 years to detect effect of both procedures on disease recurrence. Contributions of the Authors Conflicts of Interest Authors declared no con flicts of interest Data Availability Data will be available upon request to the corresponding author.

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