Conservative surgery versus colorectal resection for endometrial deposits: a systematic review and meta-analysis of surgical and long-term outcomes

Conservative surgery versus colorectal resection for endometrial deposits: a systematic review and meta-analysis of surgical and long-term outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Conservative surgery versus colorectal resection for endometrial deposits: a systematic review and meta-analysis of surgical and long-term outcomes Luke O'Brien, Stefan Morarasu, Bianca Morarasu, Paul C Neary, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2458815/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Feb, 2023 Read the published version in International Journal of Colorectal Disease → Version 1 posted 7 You are reading this latest preprint version Abstract PURPOSE: The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection. METHODS: The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes. RESULTS: Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n=1389), shaving (n=703) and discoid excision (n=742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p=0.002), comparable functional outcomes (minor LARS, p=0.30, major LARS, p=0.54), similar rates of postoperative leaks (p=0.22), pelvic abscesses (p=0.18) and rectovaginal fistula (p=0.92). On subgroup analysis, shaving had the highest recurrence rate (p=0.0007), however a lower rate of stoma formation (p<0.00001) and rectal stenosis (p=0.01). Discoid excision and formal resection were comparable. CONCLUSION: Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates. endometriosis meta-analysis surgery colorectal surgery surgery outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Introduction Endometriosis is a chronic, potentially debilitating disease affecting up to 15% of women of reproductive age 1 , 2 . Deep infiltrating endometriosis (DIE) is defined as endometrial deposits located more than 5mm beneath the peritoneal surface and can frequently affect the uterosacral ligaments, pelvic side walls, rectovaginal septum, vagina, bowel, bladder, or ureter 1 . Due to its wide pattern of distribution in the peritoneal cavity, DIE is a challenging disease, causing a wide range of symptoms, delay in diagnosis 3 , 4 and often requiring multidisciplinary involvement 5 , 6 . The bowel is affected in up to 12% of patients, with 90% of lesions located in the sigmoid colon or rectum 7 , 8 . If medical treatment fails, surgical management of endometriosis is indicated when lesions are symptomatic and impairing gastrointestinal, urinary, sexual or reproductive functions. The main surgical approaches currently used in the management of colorectal deposits include formal rectal resection and conservative surgery, either by shaving (S) of superficial endometrial deposits or by full thickness disc excision (DE) of deeper ones. The 2022 European Society of Human Reproduction and Embryology (ESHRE) Endometriosis Guidelines don’t specify which specific surgical technique is preferable and instead suggest that a tailored approach be taken for each patient 9 . This means one must first define the size, number and degree of infiltration within the intestinal wall on T2 weighted MRI sequences. MRI and endoscopy findings, patient preference, surgeon expertise and intraoperative findings usually dictate type of technique used. There has been a trend towards conservative surgery (shaving or discoid excision) as it seems to be associated with less postoperative complications based on retrospective studies, but may lead to incomplete excision, higher rate of recurrence and requirement of reoperation with resection in a challenging pelvis. Formal colorectal resection is the most radical approach which should ensure a lower risk of recurrence; however, it can be argued that it may be associated with more postoperative complications and worse functional outcomes. There is a need to define surgical standards in the management of colorectal endometriosis as currently there is no clear consensus. To enable better decision making among surgeons involved in the management of colorectal endometriosis we performed this systematic review and meta-analysis to compare surgical and long-term outcomes between conservative surgery (shaving and discoid excision) versus formal colorectal resection. Materials And Methods Literature Search and Study Selection The study protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews). The study ID is CRD42022336218. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining surgical outcomes in patients that underwent conservative (shaving or discoid excision) versus formal colorectal resection for rectal endometriosis. The following search algorithm was used: (Rectal AND Endometriosis) AND (resection). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used as search protocol and the PRISMA checklist was followed to conduct the methodology 10 (Fig. 1 ). Inclusion criteria were used according to the Problem, Intervention, Comparison and Outcome (PICO) formula. The latest search was performed on 29th May 2022. Two authors (LOB and SM) assessed the titles and abstracts of studies found in the search and the full texts of potentially eligible trials were reviewed. Disagreements were resolved by consensus-based discussion. The Newcastle-Ottawa scale (Table 1 ) and the ROBINS-I tool 11 (Fig. 2 ) were used to quantify quality of eligible studies. The references of full texts were further screened for additional eligible studies. The corresponding author was contacted to clarify data extraction if additional information was necessary. Table 1 Study characteristics First author Year of Publication Type of study Main operator Total No. of Patients C No. SR No. C Age (mean) SR Age (mean) C BMI (mean) SR BMI (mean) NOS T S DE Abo 16 2018 Retrospective Gyne 364 225 145 80 139 33.9 31.4 24.4 23.5 6 Afors 17 2016 Retrospective Gyne 92 62 47 15 30 31.2 31.1 25.3 27.3 6 Bafort 18 2020 Retrospective MDT 232 61 33 28 171 32.8 32.7 24.1 24.5 7 Bokor 19 2020 Retrospective MDT 205 66 0 66 139 29.9 32.6 23.3 24.1 6 Bonin 20 2019 Retrospective MDT 151 64 2 62 87 29.6 30.9 24.1 23.5 6 Braund 21 2020 Retrospective MDT 431 165 0 165 266 30 32.1 24.4 23.5 6 Fanfani 22 2010 Prospective MDT 136 48 0 48 88 33 32 22 23 7 Farella 23 2021 Retrospective MDT 172 108 0 108 64 30.2 31.2 23.3 23.2 7 Gornes 24 2020 Retrospective MDT 164 101 86 15 47 33.9 35.2 21.7 21.3 6 Hernandez Gutierrez 25 2019 Retrospective MDT 143 67 47 20 76 36.1 36.3 21.4 21.8 5 Hudelist 26 2018 Prospective MDT 134 32 0 32 102 34 34.5 NR NR 5 Jayot 27 2017 Retrospective Gyne 62 31 0 31 31 34 34 23.4 23.4 5 Mabrouk 28 2018 Retrospective MDT 392 330 297 33 62 34.8 35 22.3 21.8 6 Moawad 29 2011 Retrospective Gyne 22 8 0 8 14 32.4 38.9 NR NR 6 Roman 30 2010 Retrospective Gyne 46 31 0 31 15 33 32.5 NR NR 5 Roman 31 2016 Retrospective Gyne 71 46 46 0 25 41.5 41 NR NR 7 Roman 32 2018 RCT Gyne 60 27 NR NR 33 31 28 NR NR 8 Key : Gyne, gynaecologist; MDT, multidisciplinary teams; C, conservative; S, shaving; DE, disc excision; SR, segmental resection; BMI, body mass index; NOS, Newcastle-Ottawa scale Eligibility Criteria Studies written in English including comparative surgical data between conservative and colorectal resection for rectal endometrial deposits were assessed for eligibility. The primary end points were leak rate, stoma requirement and rectal endometriosis recurrence. Secondary end points included operative time, length of hospital stay, postoperative morbidity (pelvic abscesses, rectovaginal fistula, rectal stenosis) and functional outcomes measured by incidence of minor and major low anterior resection syndrome (LARS) in the studied cohort. Studies without comparative data between one conservative approach and formal resection were not included. Data Extraction and Outcomes For each eligible study the following data was recorded: author’s names, journal, year of publication, study type, total number of patients and number of patients included in each group, main operator (gynaecologist/colorectal/combined), mean age, mean BMI, surgical history, symptoms relating to rectal endometriosis (constipation, diarrhoea, dyschezia, dyspareunia), American Society for Reproductive Medicine (ASRM) endometriosis stage, Enzian C grade, operative time, postoperative complications (leak rate, stoma formation, pelvic abscesses, rectovaginal fistula and rectal stenosis) length of stay, disease recurrence, low anterior resection syndrome (LARS) grading. The type of procedure was recorded and defined as: conservative approach (C) sub-grouped as shaving of endometrial deposits (S) or discoid excision (DE) and formal segmental resection (SR). The two main groups (conservative versus resection) were compared in a meta-analytical model for group comparability (previous surgeries, ASRM endometriosis staging, Enzian C grades), operative outcomes (operative time, length of stay, need for stoma formation, leak rate, pelvic abscesses, rectovaginal fistula, rectal stenosis) and long-term outcomes (rectal recurrence, development of LARS). The operative and long terms outcomes were also analysed for the S and DE subgroups and comparing each technique with resection. Statistical Analysis As previously demonstrated 12 – 14 , random-effects models were used to measure all pooled outcomes as described by Der Simonian and Laird 16 . For dichotomous variables the odds ratio (OR) was estimated with its variance and 95% confidence interval (CI) while for continuous data mean difference was used at 95% CI. The random effects analysis weighted the natural logarithm of each study's OR by the inverse of its variance plus an estimate of the between-study variance in the presence of between-study heterogeneity. Heterogeneity between ORs for the same outcome between different studies was assessed using the I 2 inconsistency test and chi-square-based Cochran’s Q statistic test in which p < 0.05 is taken to indicate the presence of significant heterogeneity. Analyses were conducted using Review Manager 5.3. Results Eligible studies Seventeen studies 16 – 32 containing data comparing conservative versus formal resection of rectal endometriosis were included (Table 1 ). The initial search found 1647 studies. After excluding duplicates and unrelated studies based on abstract triage, 30 full texts were assessed for eligibility, out of which 17 matched the inclusion criteria and were analyzed. Year of publication of included studies ranged from 2010 to 2021. There was one randomized controlled trial (RCT), fourteen retrospective studies and two prospective. The total number of included patients was 2861, split into two groups: conservative group (C, n = 1472) and segmental resection group (SR, n = 1389). The conservative group was further split in two subgroups depending on type of procedure: shaving of endometrial deposits (S, n = 703) and discoid excision of deposits (DE, n = 742). Group comparability Mean age in the C group was 33 vs 33.4 in the SR group. Mean BMI was 23.3 in the C group and 23.4 in the SR group. The operative team was formed by both a gynecological and a colorectal surgeon in ten studies 18 – 26 , 28 , while in seven 16,17,27,29−32 the main operator was a gynecological surgeon. Previous surgery for endometriosis Five studies 16 , 19 , 20 , 21 , 23 describing 1323 patients reported how many patients had previous laparoscopies for endometriosis. No significant difference was found between the two main groups (OR: 0.84, 95% CI: [0.50, 1.4], p = 0.50, Chi 2 = 12.39, I 2 = 68%) (Fig. 3 A). Six studies 16 , 17 , 19 , 20 , 21 , 23 including 1415 patients reported how many patients had previous laparotomies. There was no significant difference between the two groups (OR: 0.77, 95% CI: [0.39, 1.53], p = 0.46, Chi 2 = 13.38, I 2 = 63% (Fig. 3 B). Endometriosis (ASRM) staging Five studies 16 , 18 – 20 , 26 including 1084 patients provided data on preoperative staging according to the ASRM endometriosis staging. Significantly more patients with stages 1 and 2 were allocated to the C group and underwent conservative surgery either by shaving or by disc excision (OR: 2.06, 95% CI: [1.28,3.33], p = 0.003, Chi 2 = 5.10, I 2 = 22%) (Fig. 4 A). There was no significant difference in allocation of stage 3 patients between the two groups (OR: 1.71, 95% CI: [0.89,3.29], p = 0.10, Chi 2 = 7.64, I 2 = 48%) (Fig. 4 B). There were less patients with stage 4 disease in the C group (OR: 0.46, 95% CI: [0.31,0.69], p = 0.0001, Chi 2 = 5.63, I 2 = 29%) (Fig. 4 C). Endometriosis Enzian C grading Six studies 16 , 19 – 21 , 23 , 26 including 1433 patients provided data on preoperative Enzian C grading of rectal endometriosis. There was no significant difference for C1 grading (OR: 2.99, 95% CI: [0.33, 27.35], p = 0.33, Chi 2 = 50.37, I 2 = 92%) (Fig. 5 A). Significantly more C2 patients underwent conservative surgery (OR: 1.83, 95% CI: [1.07, 3.14], p = 0.03, Chi 2 = 15.41, I 2 = 68%) (Fig. 5 B) while significantly more patients with C3 rectal endometriosis underwent segmental resection (OR: 0.40, 95% CI: [0.17, 0.95], p = 0.04, Chi 2 = 37.27, I 2 = 87%) (Fig. 5 C), although data showed significant heterogeneity. Operative outcomes Operative time Overall, ten studies 16 , 17 , 19 , 20 , 22 , 25 – 28 , 32 including 1739 patients measured the operative time for the two main groups. Conservative surgery was associated with a significantly shorter operative time (mean difference: 46.22 minutes, 95% CI: [18.49, 73.96], p = 0.001, Chi 2 = 100.69, I 2 = 92%) (Fig. 6 A). When the subgroups were analysed (shaving vs SR and discoid excision vs SR), shaving had the shortest operative time (mean difference: 80.58 minutes, 95% CI: [49.18, 111.97], p < 0.00001, Chi 2 = 49.20, I 2 = 92%) (Fig. 6 B). Similarly, discoid excision showed a significantly shorter operative time compared to SR (mean difference: 33.89 minutes, 95% CI: [15.85, 51.93], p = 0.0002, Chi 2 = 10.76, I 2 = 54%) (Fig. 6 C). Length of hospital stay Overall, seven studies 17 , 18 , 20 , 22 , 26 , 28 , 29 including 1159 patients had data on the length of stay. Conservative surgery was associated with a significant shorter hospital stay with a mean difference of 1.51 days, 95% CI: [0.55, 2.46], p = 0.002, Chi 2 = 29.19, I 2 = 83%) (Fig. 7 A). When analysing the subgroups, the shorter hospital stay remained valid only for the DE group (mean difference: 0.96 days, 95% CI: [0.36, 1.55], p = 0.002, Chi 2 = 10.64, I 2 = 62%) (Fig. 7 B) while S was not associated with a significant shorter stay (mean difference: 1.51 days, 95% CI: [0.73, 3.76], p = 0.002, Chi 2 = 21.25, I 2 = 91%) although data showed high heterogeneity (Fig. 7 C). Stoma requirement Thirteen studies 16–19,21,22–24,26,28,30−32 including 2483 patients provided data on the need for stoma diversion (loop ileostomy or loop colostomy). Overall, conservative surgery was associated with less stoma formation compared to segmental resection (OR: 0.23, 95% CI: [0.09, 0.57], p = 0.002, Chi 2 = 117.82, I 2 = 90%) (Fig. 8 A). On subgroup analysis, less stoma requirement was only seen when S was compared to SR with no significant heterogeneity (OR: 0.02, 95% CI: [0.01, 0.07], p < 0.00001, Chi 2 = 4.42, I 2 = 9%) (Fig. 8 B) while for DE there was no significant difference in terms of stoma requirement when compared to SR (OR: 0.59, 95% CI: [0.26, 1.35], p = 0.21, Chi 2 = 54.05, I 2 = 83%) (Fig. 8 C). Leak rate Nine studies 17 – 20 , 22 , 26 , 27 , 30 , 31 including 1129 patients provided data on the rate of postoperative leaks between the two groups. Overall, there was no significant difference in terms of leaks between the two main groups with no heterogeneity (OR: 0.55, 95% CI: [0.21, 1.44], p = 0.22, Chi 2 = 2.26, I 2 = 0%) (Fig. 9 A) and the results remained similar on subgroup analysis (Fig. 9 B, Fig. 9 C). Pelvic abscesses Ten studies 16–19,21−23,27,31,32 including 1825 patients provided data on the rate of postoperative pelvic abscesses in the two main groups. Overall, there was no significant difference between conservative surgery and segmental resection with low inter-study heterogeneity (OR: 0.73, 95% CI: [0.47, 1.16], p = 0.18, Chi 2 = 9.86, I 2 = 9%) (Fig. 10 A) and the results remained similar on subgroup analysis (Fig. 10 B, Fig. 10 C). Rectovaginal fistula Ten studies 16 – 19 , 22 , 23 , 26 , 27 , 30 , 31 including 1503 patients had data on the rate of rectovaginal fistula formation in the two main groups. Overall, there was no significant difference between conservative surgery and segmental resection (OR: 0.96, 95% CI: [0.47, 1.99], p = 0.92, Chi 2 = 9.02, I 2 = 22%) (Fig. 11 A) however on subgroup analysis shaving was associated with fewer rectovaginal fistulas with no inter-study heterogeneity (OR: 0.32, 95% CI: [0.09, 1.11], p = 0.07, Chi 2 = 0.08, I 2 = 0%) (Fig. 11 B). Discoid excision showed similar rates of rectovaginal fistulas compared to segmental resection (OR: 1.18, 95% CI: [0.62, 2.26], p = 0.61, Chi 2 = 4.09, I 2 = 0%) (Fig. 11 C). Rectal stenosis Ten studies 16 , 18 , 19 , 21 , 23 , 26 , 28 , 29 , 31 , 32 including 2083 patients provided data on the incidence of postoperative rectal stenosis between the two main groups. Overall, conservative surgery showed a smaller rate of rectal stenosis development compared to segmental resection with low heterogeneity (OR: 0.26, 95% CI: [0.09, 0.72], p = 0.009, Chi 2 = 11.35, I 2 = 21%) (Fig. 12 A). On subgroup analysis, shaving was associated with significant lower rates of rectal stenosis (OR: 0.07, 95% CI: [0.01, 0.58], p = 0.01, Chi 2 = 0.10, I 2 = 0%) (Fig. 12 B), however discoid excision showed no significant difference in terms of rectal stenosis occurrence compared to segmental resection (OR: 0.49, 95% CI: [0.11, 2.19], p = 0.35, Chi 2 = 11.46, I 2 = 48%) (Fig. 12 C). Long term outcomes Disease recurrence Four studies 16 , 25 , 28 , 31 including 698 patients analysed recurrence rates between the two groups. In all cases recurrence was confirmed intraoperatively. Overall, there were fewer recurrences seen in the segmental resection group with no inter study heterogeneity (OR: 5.56, 95% CI: [1.91, 16.18], p = 0.002, Chi 2 = 0.25, I 2 = 0%) (Fig. 13 A). Shaving was associated with a 6 fold higher recurrence rate (OR: 6.44, 95% CI: [2.19, 18.94], p = 0.0007, Chi 2 = 0.32, I 2 = 0%) (Fig. 13 B) while for discoid excision recurrence was comparable to formal resection (OR: 3.13, 95% CI: [0.71, 13.78], p = 0.13, Chi 2 = 0.29, I 2 = 0%) (Fig. 13 C). Functional outcomes (LARS) Three studies 19 , 23 , 26 including 511 patients provided data on development of low anterior resection syndrome (LARS) in the two main groups. Subgroup analysis was not possible due to insufficient data. The two main groups (C vs SR) were compared in terms of minor LARS and major LARS development. There was no significant difference in both minor LARS (OR: 0.71, 95% CI: [0.37, 1.35], p = 0.30, Chi 2 = 2.86, I 2 = 30%) (Fig. 14 A) and major LARS (OR: 1.25, 95% CI: [0.61, 2.59], p = 0.54, Chi 2 = 3.01, I 2 = 33%) (Fig. 14 B) with low inter study heterogeneity. Discussion This meta-analysis demonstrates that formal resection is associated with a significantly lower recurrence rate of rectal endometriosis compared to conservative surgery. When shaving and discoid excision were considered separately there is a 6-fold increase in recurrence with shaving and no major difference in recurrence between formal resection and discoid excision. Stoma requirement and complications such as rectal stenosis and rectovaginal fistula are lower in shaving as expected but are similar in formal resection and disc excision. When long term function is assessed, there is no difference in reported outcomes between conservative surgery and formal resection. This is the most up-to-date meta-analysis 33 – 35 on conservative versus colorectal resection for rectal endometriosis and the first one to compare both the two main groups and also the subgroups (S vs SR, DE vs SR) in terms of group comparability (previous surgeries, endometriosis staging and Enzian C grading), surgical outcomes and long-term outcomes. While shaving is associated with fewer postoperative complications and the shortest operative time, discoid excision is comparable to colorectal resection in terms of complications. Another important issue to consider is regarding patient allocation to each procedure. Our study showed that more patients with severe (stage 4) endometriosis and Enzian C grading (infiltrating rectal nodule more than 3 cm in diameter) were allocated to the colorectal resection group while more patients with stages 1 and 2 (minimal and mild) underwent conservative surgery. This is an obvious result and reflects clinical practice where surgeons choose procedures based on the severity of the disease to ensure complete removal of the nodules and avoid recurrence. The results of this study endorse such practice. It is reasonable to consider shaving for small nodules as it spares the rectal wall and reduces risk of complications, but the chance of incomplete excision and recurrence is significantly higher. Importantly, there appears to be potential long term functional issues after shaving as those undergoing resection do not have different LARS outcomes to those with shaving. It is possible that recurrent lesions in the shaving group account for the similarity in function between the two groups. For large or multiple nodules, colorectal resection offers the best chance of cure, without a significant increase in major surgical complications such as leaks, pelvis abscess or fistula formation and similar functional outcomes. There are limitations to this study based on the retrospective nature of data in most of the included studies, however due to the low prevalence of rectal endometriosis and heterogenous presentation it is difficult and unlikely to perform quality randomized controlled trials. Only one RCT 32 was done on this subject which analysed functional outcomes between conservative surgery and segmental resection and included only DIE affecting over 50% of the rectal circumference. Functional outcomes were similar between the two groups, while formal resection showed an increased risk of long-term stenosis, similar to our meta-analysis, however both shaving and discoid excision were included in the conservative group; thus, it is possible that the higher rate of rectal stenosis may have been determined by the shaving subgroup, as it was the case in our analysis. If possible, further RCTs or propensity case matched studies should aim to reduce selection bias by comparing outcomes between each of the three procedures per stage and grading of endometrial nodules. Conclusion Resection and discoid excision are associated with a lower risk of rectal endometriosis recurrence compared to shaving. Functional outcomes between conservative surgery and resection are the not different. Shaving is associated with lower complication rates but both discoid excision and resection have comparable stoma requirement and complications. For isolated smaller lesions discoid excision would be reasonable but formal resection can be considered without higher likelihood of complications or long-term impairment of function. Declarations Conflict of interest statement The authors have no conflicts of interest to disclose. The results of this study were never published or presented elsewhere. Funding statement No funding or financial assistance was received by the authors. Author contributions All authors contributed to the study conception and design. Luke O’Brien, Stefan Morarasu, Cillian Clancy, Paul C Near, Mihail Gabriel Dimofte, Sorinel Lunca designed the study and approved the study protocol. Luke O’Brien, Stefan Morarasu, Bianca Codrina Morarasu, Ana Maria Musina, Natalia Velenciuc, Cristian Ene Roata performed the literature search. Luke O’Brien, Stefan Morarasu, Cillian Clancy analysed the data. Luke O’Brien, Stefan Morarasu, Cillian Clancy, Bianca Codrina Morarasu, Ana Maria Musina, Natalia Velenciuc, Cristian Ene Roata, Diego Raimondo, Renato Seracchioli, Paolo Casadio prepared the manuscript. Diego Raimondo, Renato Seracchioli and Paolo Casadio provided raw patient data for subgroup analysis. Cillian Clancy, Paul C Neary, Mihail Gabriel Dimofte, Sorinel Lunca, Diego Raimondo, Renato Seracchioli and Paolo Casadio critically reviewed the final manuscript. All authors read and approved the final manuscript. References Wolthuis AM, Meuleman C, Tomassetti C, D'Hooghe T, de Buck van Overstraeten A, D'Hoore A. Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team. World J Gastroenterol. 2014 Nov 14;20(42):15616-23. Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21:329–339. 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Diverting stoma-related complications following colorectal endometriosis surgery: a 163-patient cohort. Eur J Obstet Gynecol Reprod Biol. 2019 Jan;232:46-53. doi: 10.1016/j.ejogrb.2018.11.008. Braund S, Hennetier C, Klapczynski C, Scattarelli A, Coget J, Bridoux V, Tuech JJ, Roman H. Risk of Postoperative Stenosis after Segmental Resection versus Disk Excision for Deep Endometriosis Infiltrating the Rectosigmoid: A Retrospective Study. J Minim Invasive Gynecol. 2021 Jan;28(1):50-56. doi: 10.1016/j.jmig.2020.04.034. Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, Minelli L. Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril. 2010 Jul;94(2):444-9. doi: 10.1016/j.fertnstert.2009.03.066. Farella M, Tuech JJ, Bridoux V, Coget J, Chati R, Resch B, Marpeau L, Roman H. Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study. J Minim Invasive Gynecol. 2021 Dec;28(12):2013-2024. doi: 10.1016/j.jmig.2021.05.007. Gornes H, Vaysse C, Leguevaque P, Gallini A, André B, Guerby P, Kirzin S, Suc B, Motton S, Rimailho J, Weyl A, Chantalat E. Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients. Arch Gynecol Obstet. 2020 Aug;302(2):383-391. doi: 10.1007/s00404-020-05604-4. Hernández Gutiérrez A, Spagnolo E, Zapardiel I, Garcia-Abadillo Seivane R, López Carrasco A, Salas Bolívar P, Pascual Miguelañez I. Post-operative complications and recurrence rate after treatment of bowel endometriosis: Comparison of three techniques. Eur J Obstet Gynecol Reprod Biol X. 2019 Jul 12;4:100083. doi: 10.1016/j.eurox.2019.100083. Hudelist G, Aas-Eng MK, Birsan T, Berger F, Sevelda U, Kirchner L, Salama M, Dauser B. Pain and fertility outcomes of nerve-sparing, full-thickness disk or segmental bowel resection for deep infiltrating endometriosis-A prospective cohort study. Acta Obstet Gynecol Scand. 2018 Dec;97(12):1438-1446. doi: 10.1111/aogs.13436. Jayot A, Nyangoh Timoh K, Bendifallah S, Ballester M, Darai E. Comparison of Laparoscopic Discoid Resection and Segmental Resection for Colorectal Endometriosis Using a Propensity Score Matching Analysis. J Minim Invasive Gynecol. 2018 Mar-Apr;25(3):440-446. doi: 10.1016/j.jmig.2017.09.019. Mabrouk M, Raimondo D, Altieri M, Arena A, Del Forno S, Moro E, Mattioli G, Iodice R, Seracchioli R. Surgical, Clinical, and Functional Outcomes in Patients with Rectosigmoid Endometriosis in the Gray Zone: 13-Year Long-Term Follow-up. J Minim Invasive Gynecol. 2019 Sep-Oct;26(6):1110-1116. doi: 10.1016/j.jmig.2018.08.031. Moawad NS, Guido R, Ramanathan R, Mansuria S, Lee T. Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis. JSLS. 2011 Jul-Sep;15(3):331-8. doi: 10.4293/108680811X13125733356431. Roman H, Rozsnayi F, Puscasiu L, Resch B, Belhiba H, Lefebure B, Scotte M, Michot F, Marpeau L, Tuech JJ. Complications associated with two laparoscopic procedures used in the management of rectal endometriosis. JSLS. 2010 Apr-Jun;14(2):169-77. doi: 10.4293/108680810X12785289143800. Roman H, Milles M, Vassilieff M, Resch B, Tuech JJ, Huet E, Darwish B, Abo C. Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol. 2016 Dec;215(6):762.e1-762.e9. doi: 10.1016/j.ajog.2016.06.055. Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, Collinet P, Tuech JJ. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod. 2018 Jan 1;33(1):47-57. doi: 10.1093/humrep/dex336. Bendifallah S, Puchar A, Vesale E, Moawad G, Daraï E, Roman H. Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2021 Mar;28(3):453-466. doi: 10.1016/j.jmig.2020.08.015. Bendifallah S, Vesale E, Daraï E, Thomassin-Naggara I, Bazot M, Tuech JJ, Abo C, Roman H. Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2020 Feb;27(2):441-451.e2. doi: 10.1016/j.jmig.2019.09.791. Heinz-Partington S, Costa W, Martins WP, Condous G. Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications. Aust N Z J Obstet Gynaecol. 2021 Apr;61(2):169-176. doi: 10.1111/ajo.13311. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Feb, 2023 Read the published version in International Journal of Colorectal Disease → Version 1 posted Editorial decision: Major revision 03 Feb, 2023 Reviews received at journal 28 Jan, 2023 Reviewers agreed at journal 20 Jan, 2023 Reviewers invited by journal 19 Jan, 2023 Editor assigned by journal 10 Jan, 2023 Submission checks completed at journal 10 Jan, 2023 First submitted to journal 09 Jan, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2458815","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":166711474,"identity":"65ec0949-ab5a-4ddf-8ed0-5675bf6d3604","order_by":0,"name":"Luke O'Brien","email":"","orcid":"","institution":"Tallaght Hospital","correspondingAuthor":false,"prefix":"","firstName":"Luke","middleName":"","lastName":"O'Brien","suffix":""},{"id":166711476,"identity":"3213f47d-3310-4a0b-86fa-d854b74a0b3d","order_by":1,"name":"Stefan Morarasu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYNCDCgYGORB94AFx6pkZGM4wMBiDtSSQoiWxAcTGp0W3vffh54qausQG/vMHHxyouZM+P+zwQ6AtdnK6Ddi1mJ05bix55tjhxAaJZGaDA8ee5W68nWYA1JJsbHYAh5YbaQySDWwHgFqY2aQ/sB3O3Tg7AaTlQOI23FqYfzb8AznsMPuPA/8OpxvOTv9ASAubZGMbM9DXyWwMB9sOJ8hL5xCw5cwxNsvGvsPGbRLJxhIH+w4bbpDOKTiQYIDHL8fbmG82fKuT7ec/+PDDgW+H5eVnp2/+8KHCTg6XFjhggzEMwCoNCChHAfINpKgeBaNgFIyCkQAAF21nMZG9/GAAAAAASUVORK5CYII=","orcid":"","institution":"Tallaght Hospital","correspondingAuthor":true,"prefix":"","firstName":"Stefan","middleName":"","lastName":"Morarasu","suffix":""},{"id":166711477,"identity":"e04ccabc-1827-4b78-91fc-8dda4a08a2d0","order_by":2,"name":"Bianca Morarasu","email":"","orcid":"","institution":"Grigore T. Popa University of Medicine and Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Bianca","middleName":"","lastName":"Morarasu","suffix":""},{"id":166711479,"identity":"ddf36200-e6ac-40fd-934f-7ce572086b4f","order_by":3,"name":"Paul C Neary","email":"","orcid":"","institution":"Tallaght Hospital","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"C","lastName":"Neary","suffix":""},{"id":166711481,"identity":"ae1847f9-fecf-4833-bc74-283ce1e43cdc","order_by":4,"name":"Ana Maria Musina","email":"","orcid":"","institution":"Institutul Regional de Oncologie","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Maria","lastName":"Musina","suffix":""},{"id":166711482,"identity":"18b13a4d-42c7-44f1-9f42-17213b607782","order_by":5,"name":"Natalia Velenciuc","email":"","orcid":"","institution":"Institutul Regional de Oncologie","correspondingAuthor":false,"prefix":"","firstName":"Natalia","middleName":"","lastName":"Velenciuc","suffix":""},{"id":166711483,"identity":"16b39f27-fee3-4b4b-a0d0-991a70cb38b2","order_by":6,"name":"Cristian Roata","email":"","orcid":"","institution":"Institutul Regional de Oncologie","correspondingAuthor":false,"prefix":"","firstName":"Cristian","middleName":"","lastName":"Roata","suffix":""},{"id":166711484,"identity":"bc611034-489f-4f1a-b725-2c904bd94d1f","order_by":7,"name":"Mihail-Gabriel Dimofte","email":"","orcid":"","institution":"Institutul Regional de Oncologie","correspondingAuthor":false,"prefix":"","firstName":"Mihail-Gabriel","middleName":"","lastName":"Dimofte","suffix":""},{"id":166711485,"identity":"2093be05-c196-4261-ae17-930c7e5a34d4","order_by":8,"name":"Sorinel Lunca","email":"","orcid":"","institution":"Institutul Regional de Oncologie","correspondingAuthor":false,"prefix":"","firstName":"Sorinel","middleName":"","lastName":"Lunca","suffix":""},{"id":166711486,"identity":"5f8eb6d7-7417-4867-bc4f-04bdb9fed957","order_by":9,"name":"Diego Raimondo","email":"","orcid":"","institution":"Policlinico S.Orsola-Malpighi","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Raimondo","suffix":""},{"id":166711487,"identity":"983dc6ba-dd31-4e8b-b9f6-55481683cb99","order_by":10,"name":"Renato Seracchioli","email":"","orcid":"","institution":"Policlinico S.Orsola-Malpighi","correspondingAuthor":false,"prefix":"","firstName":"Renato","middleName":"","lastName":"Seracchioli","suffix":""},{"id":166711488,"identity":"e35af76d-abad-4723-952c-b930a5bb4d22","order_by":11,"name":"Paolo Casadio","email":"","orcid":"","institution":"Policlinico S.Orsola-Malpighi","correspondingAuthor":false,"prefix":"","firstName":"Paolo","middleName":"","lastName":"Casadio","suffix":""},{"id":166711489,"identity":"6eb8d35a-6e89-410d-ae3d-45e5965a76a4","order_by":12,"name":"Cillian Clancy","email":"","orcid":"","institution":"Tallaght Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cillian","middleName":"","lastName":"Clancy","suffix":""}],"badges":[],"createdAt":"2023-01-09 12:14:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2458815/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2458815/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00384-023-04352-6","type":"published","date":"2023-02-27T19:03:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":31496648,"identity":"4350e2ba-050b-473e-8919-6f25368d2168","added_by":"auto","created_at":"2023-01-12 18:01:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129347,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/941ad4c2026ebf658852480d.png"},{"id":31496654,"identity":"6e8fd137-cfb7-41c3-a9db-8bb9f6b762d4","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1459565,"visible":true,"origin":"","legend":"\u003cp\u003eROBINS-I Risk of bias assessment. Assessment of risk of bias was done by two authors (LOB and SM). Each study was classified as low/moderate/serious/critical risk for each of the seven domains. Disagreements were resolved via consensus.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/6a3e2d72f1a7fb33707463db.png"},{"id":31496824,"identity":"39e50cf0-ab80-48b4-9355-1404c3d02d18","added_by":"auto","created_at":"2023-01-12 18:09:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":909111,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of previous surgical interventions for endometriosis: (a) previous laparoscopies; (b) previous laparotomies\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and previous laparotomies (n=1415, p=0.46; test for heterogeneity Cochran Q: 13.38, df: 5, p=0.02, I\u003csup\u003e2\u003c/sup\u003e: 63%)\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and previous laparoscopies (n=1323, p=0.50; test for heterogeneity Cochran Q: 12.39, df: 4, p=0.01, I\u003csup\u003e2\u003c/sup\u003e: 68%)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/089272c37e0870426ad913f5.png"},{"id":31496649,"identity":"4d8f0cae-cf9e-49e7-91c7-28e8175f9c12","added_by":"auto","created_at":"2023-01-12 18:01:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1301965,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of preoperative patient allocation, ASRM endometriosis staging: (a) stages 1 and 2; (b) stage 3; (c) stage 4\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and stage 1 and 2 (n=1084, p=0.003; test for heterogeneity Cochran Q: 5.10, df: 4, p=0.28, I\u003csup\u003e2\u003c/sup\u003e: 22%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and stage 3 (n=1084, p=0.10; test for heterogeneity Cochran Q: 7.64, df: 4, p=0.11, I\u003csup\u003e2\u003c/sup\u003e: 48%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and stage 4 (n=1084, p=0.0001; test for heterogeneity Cochran Q: 5.63, df: 4, p=0.23, I\u003csup\u003e2\u003c/sup\u003e: 29%)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/686088c7d26622410176b52e.png"},{"id":31496650,"identity":"7286b7af-bb6e-44d2-a7ba-30919c64e356","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1401577,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of preoperative patient allocation, Enzian C grading: (a) grade C1; (b) grade C2; (c) grade C3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and grade C1 (n=1433, p=0.33; test for heterogeneity Cochran Q: 50.37, df: 4, p\u0026lt;0.00001, I2: 92%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and grade C2 (n=1433, p=0.03; test for heterogeneity Cochran Q: 15.41, df: 5, p=0.009, I\u003csup\u003e2\u003c/sup\u003e: 68%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and grade C3 (n=1433, p=0.04; test for heterogeneity Cochran Q: 37.27, df: 5, p\u0026lt;0.00001, I\u003csup\u003e2\u003c/sup\u003e: 87%)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/552e7ae8348564feeb764c74.png"},{"id":31496655,"identity":"18083e97-342f-486c-812e-2e866b813424","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":48483,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of operative time: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and operative time (n=1647, p=0.001; test for heterogeneity Cochran Q: 100.69, df: 8, p\u0026lt;0.00001, I\u003csup\u003e2\u003c/sup\u003e: 92%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and operative time (n=932, p\u0026lt;0.00001; test for heterogeneity Cochran Q: 49.20, df: 4, p\u0026lt;0.00001, I\u003csup\u003e2\u003c/sup\u003e: 92%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and operative time (n=809, p=0.0002; test for heterogeneity Cochran Q: 10.76, df: 5, p=0.06, I\u003csup\u003e2\u003c/sup\u003e: 54%)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/83ab832bb145209d8cad4655.png"},{"id":31496651,"identity":"b8c81e9c-08b7-453a-a2a5-a00ba5c67764","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":38915,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of Length of stay: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and length of stay (n=1067, p=0.002; test for heterogeneity Cochran Q: 29.19, df: 5, p\u0026lt;0.0001, I\u003csup\u003e2\u003c/sup\u003e: 83%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and length of stay (n=525, p=0.19; test for heterogeneity Cochran Q: 21.25, df: 2, p\u0026lt;0.0001, I\u003csup\u003e2\u003c/sup\u003e: 91%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and length of stay (n=445, p=0.002; test for heterogeneity Cochran Q: 10.64, df: 4, p=0.03, I2: 62%)\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/9feff76297b2ed805b4dce05.png"},{"id":31496822,"identity":"482b0093-2195-4546-8921-1b1fc7fa2d4c","added_by":"auto","created_at":"2023-01-12 18:09:14","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":48551,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of stoma requirement: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and stoma requirement (n=2483, p=0.002; test for heterogeneity Cochran Q: 117.82, df: 4, p\u0026lt;0.00001, I\u003csup\u003e2\u003c/sup\u003e: 90%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and stoma requirement (n=924, p\u0026lt;0.00001; test for heterogeneity Cochran Q: 4.42, df: 4, p=0.35, I\u003csup\u003e2\u003c/sup\u003e: 9%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and stoma requirement (n=1674, p=0.21; test for heterogeneity Cochran Q: 54.05, df: 9, p\u0026lt;0.00001, I\u003csup\u003e2\u003c/sup\u003e: 83%)\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/7403d0e4ce3ccb88e97e87a6.png"},{"id":31496658,"identity":"e347c1f3-4657-439c-8501-85982fb80d34","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":41250,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of leak rate: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and leak rate (n=1129, p=0.22; test for heterogeneity Cochran Q: 2.26, df: 8, p=0.97, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and leak rate (n=237, p=0.59; test for heterogeneity Cochran Q: 0.01, df: 1, p=0.93, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and leak rate (n=777, p=0.37; test for heterogeneity Cochran Q: 2.30, df: 6, p=0.89, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/c11b71bd0267a90ec11622a4.png"},{"id":31497248,"identity":"095433fd-ec6e-4d54-9942-79a254c216f8","added_by":"auto","created_at":"2023-01-12 18:17:14","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":43045,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of pelvic abscesses: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and pelvic abscesses (n=1825, p=0.18; test for heterogeneity Cochran Q: 9.86, df: 9, p=0.36, I\u003csup\u003e2\u003c/sup\u003e: 9%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and pelvic abscesses (n=432, p=0.13; test for heterogeneity Cochran Q: 0.63, df: 2, p=0.73, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and pelvic abscesses (n=1270, p=0.60; test for heterogeneity Cochran Q: 9.32, df: 6, p=0.16, I2: 36%)\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/3ae9ae61b8f95190d6e47d7a.png"},{"id":31496660,"identity":"75667301-b0ce-43dd-8684-12cc8c50dd47","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":43227,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of rectovaginal fistula: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and rectovaginal fistula (n=1503, p=0.92; test for heterogeneity Cochran Q: 9.02, df: 7, p=0.25, I\u003csup\u003e2\u003c/sup\u003e: 22%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and rectovaginal fistula (n=361, p=0.07; test for heterogeneity Cochran Q: 0.08, df: 1, p=0.77, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and rectovaginal fistula (n=1190 p=0.61; test for heterogeneity Cochran Q: 4.09, df: 5, p=0.54, I\u003csup\u003e2\u003c/sup\u003e:0%)\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/8ab1b3a6a5d89d35a3fdc17e.png"},{"id":31496661,"identity":"1b11013b-1ee8-467d-bbcc-95ff915c1a20","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":43233,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of rectal stenosis: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and rectal stenosis (n=2083, p=0.009; test for heterogeneity Cochran Q: 11.35, df: 9, p=0.25, I\u003csup\u003e2\u003c/sup\u003e: 21%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and rectal stenosis (n=714, p=0.01; test for heterogeneity Cochran Q: 0.10, df: 1, p=0.76, I2: 0%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and rectal stenosis (n=1278, p=0.35; test for heterogeneity Cochran Q: 11.46, df: 6, p=0.08, I\u003csup\u003e2\u003c/sup\u003e:48%)\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/23d519faf0fe5d69afa33a11.png"},{"id":31496825,"identity":"9376bb73-f940-4c0e-b4a7-74ae73c029f4","added_by":"auto","created_at":"2023-01-12 18:09:14","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":37501,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of rectal recurrence: (a) C versus SR; (b) S versus SR; (c) DE versus SR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and rectal recurrence (n=698, p=0.002; test for heterogeneity Cochran Q: 0.25, df: 3, p=0.97, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; S versus SR and rectal recurrence (n=630, p=0.0007; test for heterogeneity Cochran Q: 0.32, df: 3, p=0.96, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e\n\u003cp\u003e(c)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; DE versus SR and rectal recurrence (n=236, p=0.13; test for heterogeneity Cochran Q: 0.29, df: 2, p=0.87, I\u003csup\u003e2\u003c/sup\u003e: 0%)\u003c/p\u003e","description":"","filename":"13.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/f52fc6cc21d52f7d43f5cb2d.png"},{"id":31496659,"identity":"c8b9fd2c-47f4-4e95-9a59-8d453cd84667","added_by":"auto","created_at":"2023-01-12 18:01:14","extension":"png","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":745599,"visible":true,"origin":"","legend":"\u003cp\u003eMeta analysis of LARS: (a) minor LARS; (b) major LARS\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Each study is shown by the point estimate of the odds ratio/mean difference (OR/MD; square proportional to the weight of each study) and 95% confidence interval (CI) for the OR (extending lines); the combined ORs/mean difference and 95% CIs by random effects calculations are shown by diamonds.\u003c/p\u003e\n\u003cp\u003e(a)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and minor LARS (n=511, p=0.30; test for heterogeneity Cochran Q: 2.86, df: 2, p=0.24, I2: 30%)\u003c/p\u003e\n\u003cp\u003e(b)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; C versus SR and major LARS (n=511, p=0.54; test for heterogeneity Cochran Q: 3.01, df: 2, p=0.22, I\u003csup\u003e2\u003c/sup\u003e: 33%)\u003c/p\u003e","description":"","filename":"14.png","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/7f8981e286653c184b05a9af.png"},{"id":44720553,"identity":"2c526dd0-4f8d-4336-9c10-3acbccb4416f","added_by":"auto","created_at":"2023-10-16 19:12:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2487077,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2458815/v1/505084da-50c5-4b28-b42a-7253c9016cb4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Conservative surgery versus colorectal resection for endometrial deposits: a systematic review and meta-analysis of surgical and long-term outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a chronic, potentially debilitating disease affecting up to 15% of women of reproductive age\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Deep infiltrating endometriosis (DIE) is defined as endometrial deposits located more than 5mm beneath the peritoneal surface and can frequently affect the uterosacral ligaments, pelvic side walls, rectovaginal septum, vagina, bowel, bladder, or ureter\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Due to its wide pattern of distribution in the peritoneal cavity, DIE is a challenging disease, causing a wide range of symptoms, delay in diagnosis\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and often requiring multidisciplinary involvement\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The bowel is affected in up to 12% of patients, with 90% of lesions located in the sigmoid colon or rectum\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIf medical treatment fails, surgical management of endometriosis is indicated when lesions are symptomatic and impairing gastrointestinal, urinary, sexual or reproductive functions. The main surgical approaches currently used in the management of colorectal deposits include formal rectal resection and conservative surgery, either by shaving (S) of superficial endometrial deposits or by full thickness disc excision (DE) of deeper ones. The 2022 European Society of Human Reproduction and Embryology (ESHRE) Endometriosis Guidelines don\u0026rsquo;t specify which specific surgical technique is preferable and instead suggest that a tailored approach be taken for each patient\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. This means one must first define the size, number and degree of infiltration within the intestinal wall on T2 weighted MRI sequences. MRI and endoscopy findings, patient preference, surgeon expertise and intraoperative findings usually dictate type of technique used.\u003c/p\u003e \u003cp\u003eThere has been a trend towards conservative surgery (shaving or discoid excision) as it seems to be associated with less postoperative complications based on retrospective studies, but may lead to incomplete excision, higher rate of recurrence and requirement of reoperation with resection in a challenging pelvis. Formal colorectal resection is the most radical approach which should ensure a lower risk of recurrence; however, it can be argued that it may be associated with more postoperative complications and worse functional outcomes. There is a need to define surgical standards in the management of colorectal endometriosis as currently there is no clear consensus. To enable better decision making among surgeons involved in the management of colorectal endometriosis we performed this systematic review and meta-analysis to compare surgical and long-term outcomes between conservative surgery (shaving and discoid excision) versus formal colorectal resection.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003e \u003cb\u003eLiterature Search and Study Selection\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The study protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews). The study ID is CRD42022336218. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining surgical outcomes in patients that underwent conservative (shaving or discoid excision) versus formal colorectal resection for rectal endometriosis. The following search algorithm was used: (Rectal AND Endometriosis) AND (resection). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used as search protocol and the PRISMA checklist was followed to conduct the methodology\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Inclusion criteria were used according to the Problem, Intervention, Comparison and Outcome (PICO) formula. The latest search was performed on 29th May 2022. Two authors (LOB and SM) assessed the titles and abstracts of studies found in the search and the full texts of potentially eligible trials were reviewed. Disagreements were resolved by consensus-based discussion. The Newcastle-Ottawa scale (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and the ROBINS-I tool\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) were used to quantify quality of eligible studies. The references of full texts were further screened for additional eligible studies. The corresponding author was contacted to clarify data extraction if additional information was necessary.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFirst author\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYear of Publication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMain operator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal No. of Patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eC No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSR No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eC Age\u003c/p\u003e \u003cp\u003e(mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSR Age\u003c/p\u003e \u003cp\u003e(mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eC BMI\u003c/p\u003e \u003cp\u003e(mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSR BMI\u003c/p\u003e \u003cp\u003e(mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eT\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eS\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eDE\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbo\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfors\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e31.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBafort\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBokor\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBonin\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBraund\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFanfani\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarella\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGornes\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e35.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHernandez Gutierrez\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHudelist\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJayot\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMabrouk\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoawad\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoman\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoman\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e41.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoman\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGyne\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"14\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eKey\u003c/span\u003e: Gyne, gynaecologist; MDT, multidisciplinary teams; C, conservative; S, shaving; DE, disc excision; SR, segmental resection; BMI, body mass index; NOS, Newcastle-Ottawa scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility Criteria\u003c/h2\u003e \u003cp\u003eStudies written in English including comparative surgical data between conservative and colorectal resection for rectal endometrial deposits were assessed for eligibility. The primary end points were leak rate, stoma requirement and rectal endometriosis recurrence. Secondary end points included operative time, length of hospital stay, postoperative morbidity (pelvic abscesses, rectovaginal fistula, rectal stenosis) and functional outcomes measured by incidence of minor and major low anterior resection syndrome (LARS) in the studied cohort. Studies without comparative data between one conservative approach and formal resection were not included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction and Outcomes\u003c/h2\u003e \u003cp\u003eFor each eligible study the following data was recorded: author\u0026rsquo;s names, journal, year of publication, study type, total number of patients and number of patients included in each group, main operator (gynaecologist/colorectal/combined), mean age, mean BMI, surgical history, symptoms relating to rectal endometriosis (constipation, diarrhoea, dyschezia, dyspareunia), American Society for Reproductive Medicine (ASRM) endometriosis stage, Enzian C grade, operative time, postoperative complications (leak rate, stoma formation, pelvic abscesses, rectovaginal fistula and rectal stenosis) length of stay, disease recurrence, low anterior resection syndrome (LARS) grading. The type of procedure was recorded and defined as: conservative approach (C) sub-grouped as shaving of endometrial deposits (S) or discoid excision (DE) and formal segmental resection (SR). The two main groups (conservative versus resection) were compared in a meta-analytical model for group comparability (previous surgeries, ASRM endometriosis staging, Enzian C grades), operative outcomes (operative time, length of stay, need for stoma formation, leak rate, pelvic abscesses, rectovaginal fistula, rectal stenosis) and long-term outcomes (rectal recurrence, development of LARS). The operative and long terms outcomes were also analysed for the S and DE subgroups and comparing each technique with resection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAs previously demonstrated\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, random-effects models were used to measure all pooled outcomes as described by Der Simonian and Laird\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. For dichotomous variables the odds ratio (OR) was estimated with its variance and 95% confidence interval (CI) while for continuous data mean difference was used at 95% CI. The random effects analysis weighted the natural logarithm of each study's OR by the inverse of its variance plus an estimate of the between-study variance in the presence of between-study heterogeneity. Heterogeneity between ORs for the same outcome between different studies was assessed using the I\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e inconsistency test and chi-square-based Cochran\u0026rsquo;s Q statistic test in which p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is taken to indicate the presence of significant heterogeneity. Analyses were conducted using Review Manager 5.3.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEligible studies\u003c/h2\u003e \u003cp\u003eSeventeen studies\u003csup\u003e\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e containing data comparing conservative versus formal resection of rectal endometriosis were included (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The initial search found 1647 studies. After excluding duplicates and unrelated studies based on abstract triage, 30 full texts were assessed for eligibility, out of which 17 matched the inclusion criteria and were analyzed. Year of publication of included studies ranged from 2010 to 2021. There was one randomized controlled trial (RCT), fourteen retrospective studies and two prospective. The total number of included patients was 2861, split into two groups: conservative group (C, n\u0026thinsp;=\u0026thinsp;1472) and segmental resection group (SR, n\u0026thinsp;=\u0026thinsp;1389). The conservative group was further split in two subgroups depending on type of procedure: shaving of endometrial deposits (S, n\u0026thinsp;=\u0026thinsp;703) and discoid excision of deposits (DE, n\u0026thinsp;=\u0026thinsp;742).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGroup comparability\u003c/h2\u003e \u003cp\u003eMean age in the C group was 33 vs 33.4 in the SR group. Mean BMI was 23.3 in the C group and 23.4 in the SR group. The operative team was formed by both a gynecological and a colorectal surgeon in ten studies\u003csup\u003e\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, while in seven\u003csup\u003e16,17,27,29\u0026minus;32\u003c/sup\u003e the main operator was a gynecological surgeon.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003ePrevious surgery for endometriosis\u003c/h2\u003e \u003cp\u003eFive studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e describing 1323 patients reported how many patients had previous laparoscopies for endometriosis. No significant difference was found between the two main groups (OR: 0.84, 95% CI: [0.50, 1.4], p\u0026thinsp;=\u0026thinsp;0.50, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;12.39, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;68%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSix studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e including 1415 patients reported how many patients had previous laparotomies. There was no significant difference between the two groups (OR: 0.77, 95% CI: [0.39, 1.53], p\u0026thinsp;=\u0026thinsp;0.46, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;13.38, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;63% (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eEndometriosis (ASRM) staging\u003c/h2\u003e \u003cp\u003eFive studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e including 1084 patients provided data on preoperative staging according to the ASRM endometriosis staging. Significantly more patients with stages 1 and 2 were allocated to the C group and underwent conservative surgery either by shaving or by disc excision (OR: 2.06, 95% CI: [1.28,3.33], p\u0026thinsp;=\u0026thinsp;0.003, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;5.10, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;22%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). There was no significant difference in allocation of stage 3 patients between the two groups (OR: 1.71, 95% CI: [0.89,3.29], p\u0026thinsp;=\u0026thinsp;0.10, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;7.64, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;48%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB). There were less patients with stage 4 disease in the C group (OR: 0.46, 95% CI: [0.31,0.69], p\u0026thinsp;=\u0026thinsp;0.0001, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;5.63, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;29%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eEndometriosis Enzian C grading\u003c/h2\u003e \u003cp\u003eSix studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e including 1433 patients provided data on preoperative Enzian C grading of rectal endometriosis. There was no significant difference for C1 grading (OR: 2.99, 95% CI: [0.33, 27.35], p\u0026thinsp;=\u0026thinsp;0.33, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;50.37, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;92%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA). Significantly more C2 patients underwent conservative surgery (OR: 1.83, 95% CI: [1.07, 3.14], p\u0026thinsp;=\u0026thinsp;0.03, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;15.41, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;68%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB) while significantly more patients with C3 rectal endometriosis underwent segmental resection (OR: 0.40, 95% CI: [0.17, 0.95], p\u0026thinsp;=\u0026thinsp;0.04, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;37.27, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;87%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eC), although data showed significant heterogeneity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOperative outcomes\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eOperative time\u003c/h2\u003e \u003cp\u003eOverall, ten studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e including 1739 patients measured the operative time for the two main groups. Conservative surgery was associated with a significantly shorter operative time (mean difference: 46.22 minutes, 95% CI: [18.49, 73.96], p\u0026thinsp;=\u0026thinsp;0.001, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;100.69, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;92%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eA). When the subgroups were analysed (shaving vs SR and discoid excision vs SR), shaving had the shortest operative time (mean difference: 80.58 minutes, 95% CI: [49.18, 111.97], p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;49.20, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;92%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eB). Similarly, discoid excision showed a significantly shorter operative time compared to SR (mean difference: 33.89 minutes, 95% CI: [15.85, 51.93], p\u0026thinsp;=\u0026thinsp;0.0002, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;10.76, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;54%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eLength of hospital stay\u003c/h2\u003e \u003cp\u003eOverall, seven studies\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e including 1159 patients had data on the length of stay. Conservative surgery was associated with a significant shorter hospital stay with a mean difference of 1.51 days, 95% CI: [0.55, 2.46], p\u0026thinsp;=\u0026thinsp;0.002, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;29.19, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;83%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eA). When analysing the subgroups, the shorter hospital stay remained valid only for the DE group (mean difference: 0.96 days, 95% CI: [0.36, 1.55], p\u0026thinsp;=\u0026thinsp;0.002, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;10.64, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;62%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eB) while S was not associated with a significant shorter stay (mean difference: 1.51 days, 95% CI: [0.73, 3.76], p\u0026thinsp;=\u0026thinsp;0.002, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;21.25, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;91%) although data showed high heterogeneity (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eStoma requirement\u003c/h2\u003e \u003cp\u003eThirteen studies\u003csup\u003e16\u0026ndash;19,21,22\u0026ndash;24,26,28,30\u0026minus;32\u003c/sup\u003e including 2483 patients provided data on the need for stoma diversion (loop ileostomy or loop colostomy). Overall, conservative surgery was associated with less stoma formation compared to segmental resection (OR: 0.23, 95% CI: [0.09, 0.57], p\u0026thinsp;=\u0026thinsp;0.002, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;117.82, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;90%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003eA). On subgroup analysis, less stoma requirement was only seen when S was compared to SR with no significant heterogeneity (OR: 0.02, 95% CI: [0.01, 0.07], p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.42, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;9%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003eB) while for DE there was no significant difference in terms of stoma requirement when compared to SR (OR: 0.59, 95% CI: [0.26, 1.35], p\u0026thinsp;=\u0026thinsp;0.21, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;54.05, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;83%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eLeak rate\u003c/h2\u003e \u003cp\u003eNine studies\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e including 1129 patients provided data on the rate of postoperative leaks between the two groups. Overall, there was no significant difference in terms of leaks between the two main groups with no heterogeneity (OR: 0.55, 95% CI: [0.21, 1.44], p\u0026thinsp;=\u0026thinsp;0.22, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.26, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eA) and the results remained similar on subgroup analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eB, Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003ePelvic abscesses\u003c/h2\u003e \u003cp\u003eTen studies\u003csup\u003e16\u0026ndash;19,21\u0026minus;23,27,31,32\u003c/sup\u003e including 1825 patients provided data on the rate of postoperative pelvic abscesses in the two main groups. Overall, there was no significant difference between conservative surgery and segmental resection with low inter-study heterogeneity (OR: 0.73, 95% CI: [0.47, 1.16], p\u0026thinsp;=\u0026thinsp;0.18, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;9.86, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;9%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003eA) and the results remained similar on subgroup analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003eB, Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eRectovaginal fistula\u003c/h2\u003e \u003cp\u003eTen studies\u003csup\u003e\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e including 1503 patients had data on the rate of rectovaginal fistula formation in the two main groups. Overall, there was no significant difference between conservative surgery and segmental resection (OR: 0.96, 95% CI: [0.47, 1.99], p\u0026thinsp;=\u0026thinsp;0.92, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;9.02, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;22%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003eA) however on subgroup analysis shaving was associated with fewer rectovaginal fistulas with no inter-study heterogeneity (OR: 0.32, 95% CI: [0.09, 1.11], p\u0026thinsp;=\u0026thinsp;0.07, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.08, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003eB). Discoid excision showed similar rates of rectovaginal fistulas compared to segmental resection (OR: 1.18, 95% CI: [0.62, 2.26], p\u0026thinsp;=\u0026thinsp;0.61, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.09, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eRectal stenosis\u003c/h2\u003e \u003cp\u003eTen studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e including 2083 patients provided data on the incidence of postoperative rectal stenosis between the two main groups. Overall, conservative surgery showed a smaller rate of rectal stenosis development compared to segmental resection with low heterogeneity (OR: 0.26, 95% CI: [0.09, 0.72], p\u0026thinsp;=\u0026thinsp;0.009, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;11.35, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;21%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003eA). On subgroup analysis, shaving was associated with significant lower rates of rectal stenosis (OR: 0.07, 95% CI: [0.01, 0.58], p\u0026thinsp;=\u0026thinsp;0.01, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.10, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003eB), however discoid excision showed no significant difference in terms of rectal stenosis occurrence compared to segmental resection (OR: 0.49, 95% CI: [0.11, 2.19], p\u0026thinsp;=\u0026thinsp;0.35, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;11.46, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;48%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLong term outcomes\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eDisease recurrence\u003c/h2\u003e \u003cp\u003eFour studies\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e including 698 patients analysed recurrence rates between the two groups. In all cases recurrence was confirmed intraoperatively. Overall, there were fewer recurrences seen in the segmental resection group with no inter study heterogeneity (OR: 5.56, 95% CI: [1.91, 16.18], p\u0026thinsp;=\u0026thinsp;0.002, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.25, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e13\u003c/span\u003eA). Shaving was associated with a 6 fold higher recurrence rate (OR: 6.44, 95% CI: [2.19, 18.94], p\u0026thinsp;=\u0026thinsp;0.0007, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.32, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e13\u003c/span\u003eB) while for discoid excision recurrence was comparable to formal resection (OR: 3.13, 95% CI: [0.71, 13.78], p\u0026thinsp;=\u0026thinsp;0.13, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.29, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e13\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eFunctional outcomes (LARS)\u003c/h2\u003e \u003cp\u003eThree studies\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e including 511 patients provided data on development of low anterior resection syndrome (LARS) in the two main groups. Subgroup analysis was not possible due to insufficient data. The two main groups (C vs SR) were compared in terms of minor LARS and major LARS development. There was no significant difference in both minor LARS (OR: 0.71, 95% CI: [0.37, 1.35], p\u0026thinsp;=\u0026thinsp;0.30, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.86, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;30%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig14\" class=\"InternalRef\"\u003e14\u003c/span\u003eA) and major LARS (OR: 1.25, 95% CI: [0.61, 2.59], p\u0026thinsp;=\u0026thinsp;0.54, Chi\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3.01, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;33%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig14\" class=\"InternalRef\"\u003e14\u003c/span\u003eB) with low inter study heterogeneity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis meta-analysis demonstrates that formal resection is associated with a significantly lower recurrence rate of rectal endometriosis compared to conservative surgery. When shaving and discoid excision were considered separately there is a 6-fold increase in recurrence with shaving and no major difference in recurrence between formal resection and discoid excision. Stoma requirement and complications such as rectal stenosis and rectovaginal fistula are lower in shaving as expected but are similar in formal resection and disc excision. When long term function is assessed, there is no difference in reported outcomes between conservative surgery and formal resection.\u003c/p\u003e \u003cp\u003eThis is the most up-to-date meta-analysis\u003csup\u003e\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e on conservative versus colorectal resection for rectal endometriosis and the first one to compare both the two main groups and also the subgroups (S vs SR, DE vs SR) in terms of group comparability (previous surgeries, endometriosis staging and Enzian C grading), surgical outcomes and long-term outcomes. While shaving is associated with fewer postoperative complications and the shortest operative time, discoid excision is comparable to colorectal resection in terms of complications. Another important issue to consider is regarding patient allocation to each procedure. Our study showed that more patients with severe (stage 4) endometriosis and Enzian C grading (infiltrating rectal nodule more than 3 cm in diameter) were allocated to the colorectal resection group while more patients with stages 1 and 2 (minimal and mild) underwent conservative surgery. This is an obvious result and reflects clinical practice where surgeons choose procedures based on the severity of the disease to ensure complete removal of the nodules and avoid recurrence. The results of this study endorse such practice. It is reasonable to consider shaving for small nodules as it spares the rectal wall and reduces risk of complications, but the chance of incomplete excision and recurrence is significantly higher. Importantly, there appears to be potential long term functional issues after shaving as those undergoing resection do not have different LARS outcomes to those with shaving. It is possible that recurrent lesions in the shaving group account for the similarity in function between the two groups. For large or multiple nodules, colorectal resection offers the best chance of cure, without a significant increase in major surgical complications such as leaks, pelvis abscess or fistula formation and similar functional outcomes.\u003c/p\u003e \u003cp\u003eThere are limitations to this study based on the retrospective nature of data in most of the included studies, however due to the low prevalence of rectal endometriosis and heterogenous presentation it is difficult and unlikely to perform quality randomized controlled trials. Only one RCT\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e was done on this subject which analysed functional outcomes between conservative surgery and segmental resection and included only DIE affecting over 50% of the rectal circumference. Functional outcomes were similar between the two groups, while formal resection showed an increased risk of long-term stenosis, similar to our meta-analysis, however both shaving and discoid excision were included in the conservative group; thus, it is possible that the higher rate of rectal stenosis may have been determined by the shaving subgroup, as it was the case in our analysis. If possible, further RCTs or propensity case matched studies should aim to reduce selection bias by comparing outcomes between each of the three procedures per stage and grading of endometrial nodules.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eResection and discoid excision are associated with a lower risk of rectal endometriosis recurrence compared to shaving. Functional outcomes between conservative surgery and resection are the not different. Shaving is associated with lower complication rates but both discoid excision and resection have comparable stoma requirement and complications. For isolated smaller lesions discoid excision would be reasonable but formal resection can be considered without higher likelihood of complications or long-term impairment of function.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConflict of interest statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose. The results of this study were never published or presented elsewhere.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding or financial assistance was received by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Luke O\u0026rsquo;Brien, Stefan Morarasu, Cillian Clancy, Paul C Near, Mihail Gabriel Dimofte, Sorinel Lunca designed the study and approved the study protocol. Luke O\u0026rsquo;Brien, Stefan Morarasu, Bianca Codrina Morarasu, Ana Maria Musina, Natalia Velenciuc, Cristian Ene Roata performed the literature search. Luke O\u0026rsquo;Brien, Stefan Morarasu, Cillian Clancy analysed the data. Luke O\u0026rsquo;Brien, Stefan Morarasu, Cillian Clancy, Bianca Codrina Morarasu, Ana Maria Musina, Natalia Velenciuc, Cristian Ene Roata, Diego Raimondo, Renato Seracchioli, Paolo Casadio prepared the manuscript. Diego Raimondo, Renato Seracchioli and Paolo Casadio provided raw patient data for subgroup analysis. Cillian Clancy, Paul C Neary, Mihail Gabriel Dimofte, Sorinel Lunca, Diego Raimondo, Renato Seracchioli and Paolo Casadio critically reviewed the final manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cspan style=\"text-align: inherit;\"\u003eWolthuis AM, Meuleman C, Tomassetti C, D\u0026apos;Hooghe T, de Buck van Overstraeten A, D\u0026apos;Hoore A. Bowel endometriosis: colorectal surgeon\u0026apos;s perspective in a multidisciplinary surgical team. World J Gastroenterol. 2014 Nov 14;20(42):15616-23. \u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAbrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21:329\u0026ndash;339. \u003c/li\u003e\n\u003cli\u003eSurrey E, Soliman AM, Trenz H, Blauer-Peterson C, Sluis A. Impact of Endometriosis Diagnostic Delays on Healthcare Resource Utilization and Costs. Adv Ther. 2020 Mar;37(3):1087-1099.\u003c/li\u003e\n\u003cli\u003eGhai V, Jan H, Shakir F, Haines P, Kent A. Diagnostic delay for superficial and deep endometriosis in the United Kingdom. J Obstet Gynaecol. 2020 Jan;40(1):83-89.\u003c/li\u003e\n\u003cli\u003eFalcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018 Mar;131(3):557-571.\u003c/li\u003e\n\u003cli\u003eVercellini P, Facchin F, Buggio L, Barbara G, Berlanda N, Frattaruolo MP, Somigliana E. 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Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009.\u003c/li\u003e\n\u003cli\u003eLiberati A, Altman DG, Tetzlaff J et al (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700.\u003c/li\u003e\n\u003cli\u003eSterne JA, Hern\u0026aacute;n MA, Reeves BC et al (2016). ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919.\u003c/li\u003e\n\u003cli\u003eMorarasu S, O\u0026apos;Brien L, Clancy C, Dietrich D, Maurer CA, Frasson M, Garcia-Granero E, Martin ST (2021). A systematic review and meta-analysis comparing surgical and oncological outcomes of upper rectal, rectosigmoid and sigmoid tumours. Eur J Surg Oncol 47(9):2421-2428.\u003c/li\u003e\n\u003cli\u003eMorarasu S, Clancy C, Cronin CT, Matsuda T, Heneghan HM, Winter DC. Segmental versus extended colectomy for tumours of the transverse colon: a systematic review and meta-analysis. Colorectal Dis. 2021 Mar;23(3):625-634.\u003c/li\u003e\n\u003cli\u003eMorarasu S, Clancy C, Ghetu N, Musina AM, Velenciuc N, Iacob S, Frunza T, Roata CE, Lunca S, Dimofte GM. Impact of Quilting Sutures on Surgical Outcomes After Mastectomy: A Systematic Review and Meta-Analysis. Ann Surg Oncol. 2022 Jun;29(6):3785-3797.\u003c/li\u003e\n\u003cli\u003eDerSimonian R, Laird N (1986). Meta-analysis in clinical trials. Control Clin Trials 7(3):177-88.\u003c/li\u003e\n\u003cli\u003eAbo C, Moatassim S, Marty N, Saint Ghislain M, Huet E, Bridoux V, Tuech JJ, Roman H. Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril. 2018 Jan;109(1):172-178.e1. doi: 10.1016/j.fertnstert.2017.10.001. \u003c/li\u003e\n\u003cli\u003eAfors K, Centini G, Fernandes R, Murtada R, Zupi E, Akladios C, Wattiez A. Segmental and Discoid Resection are Preferential to Bowel Shaving for Medium-Term Symptomatic Relief in Patients With Bowel Endometriosis. J Minim Invasive Gynecol. 2016 Nov-Dec;23(7):1123-1129. doi: 10.1016/j.jmig.2016.08.813. \u003c/li\u003e\n\u003cli\u003eBafort C, van Elst B, Neutens S, Meuleman C, Laenen A, d\u0026apos;Hoore A, Wolthuis A, Tomassetti C. Outcome after surgery for deep endometriosis infiltrating the rectum. Fertil Steril. 2020 Jun;113(6):1319-1327.e3. doi: 10.1016/j.fertnstert.2020.02.108. \u003c/li\u003e\n\u003cli\u003eBokor A, Hudelist G, Dob\u0026oacute; N, Dauser B, Farella M, Brubel R, Tuech JJ, Roman H. Low anterior resection syndrome following different surgical approaches for low rectal endometriosis: A retrospective multicenter study. 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Hum Reprod. 2018 Jan 1;33(1):47-57. doi: 10.1093/humrep/dex336.\u003c/li\u003e\n\u003cli\u003eBendifallah S, Puchar A, Vesale E, Moawad G, Dara\u0026iuml; E, Roman H. Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2021 Mar;28(3):453-466. doi: 10.1016/j.jmig.2020.08.015.\u003c/li\u003e\n\u003cli\u003eBendifallah S, Vesale E, Dara\u0026iuml; E, Thomassin-Naggara I, Bazot M, Tuech JJ, Abo C, Roman H. Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2020 Feb;27(2):441-451.e2. doi: 10.1016/j.jmig.2019.09.791.\u003c/li\u003e\n\u003cli\u003eHeinz-Partington S, Costa W, Martins WP, Condous G. Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications. Aust N Z J Obstet Gynaecol. 2021 Apr;61(2):169-176. doi: 10.1111/ajo.13311.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"endometriosis, meta-analysis, surgery, colorectal surgery, surgery outcomes","lastPublishedDoi":"10.21203/rs.3.rs-2458815/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2458815/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePURPOSE: \u003c/strong\u003eThe optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS: \u003c/strong\u003eThe study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes. \u003cstrong\u003e\u003cbr\u003e\nRESULTS: \u003c/strong\u003eSeventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n=1389), shaving (n=703) and discoid excision (n=742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p=0.002), comparable functional outcomes (minor LARS, p=0.30, major LARS, p=0.54), similar rates of postoperative leaks (p=0.22), pelvic abscesses (p=0.18) and rectovaginal fistula (p=0.92). On subgroup analysis, shaving had the highest recurrence rate (p=0.0007), however a lower rate of stoma formation (p\u0026lt;0.00001) and rectal stenosis (p=0.01). Discoid excision and formal resection were comparable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION: \u003c/strong\u003eColorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.\u003c/p\u003e","manuscriptTitle":"Conservative surgery versus colorectal resection for endometrial deposits: a systematic review and meta-analysis of surgical and long-term outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-12 18:01:08","doi":"10.21203/rs.3.rs-2458815/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-02-04T04:26:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-01-28T08:27:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"483e1aaf-82d5-4df6-aa5f-ee158079b810","date":"2023-01-20T08:45:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-01-19T19:37:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-01-11T01:07:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-01-11T01:07:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2023-01-09T12:13:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bf87cb11-2344-47a9-aabc-af9dc5f585b9","owner":[],"postedDate":"January 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T19:10:39+00:00","versionOfRecord":{"articleIdentity":"rs-2458815","link":"https://doi.org/10.1007/s00384-023-04352-6","journal":{"identity":"international-journal-of-colorectal-disease","isVorOnly":false,"title":"International Journal of Colorectal Disease"},"publishedOn":"2023-02-27 19:03:55","publishedOnDateReadable":"February 27th, 2023"},"versionCreatedAt":"2023-01-12 18:01:08","video":"","vorDoi":"10.1007/s00384-023-04352-6","vorDoiUrl":"https://doi.org/10.1007/s00384-023-04352-6","workflowStages":[]},"version":"v1","identity":"rs-2458815","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2458815","identity":"rs-2458815","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}