Validation of the Deep Pelvis Endometriosis Index (dPEI) to evaluate surgical outcomes of robotic-assisted surgery for endometriosis

Validation of the Deep Pelvis Endometriosis Index (dPEI) to evaluate surgical outcomes of robotic-assisted surgery for endometriosis | 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 Validation of the Deep Pelvis Endometriosis Index (dPEI) to evaluate surgical outcomes of robotic-assisted surgery for endometriosis Adèle Reilhac, Shiwa Mansournia, Yohann Dabi, Clément Ferrier, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7988692/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background The Deep Pelvic Endometriosis Index (dPEI) is a preoperative MRI-based score initially validated to predict surgical outcomes in patients undergoing laparoscopic treatment for deep pelvic endometriosis (DPE). Its applicability in robotic-assisted laparoscopy (RAL) has not yet been established. Objective This study aimed to evaluate whether the dPEI can predict surgical outcomes following RAL for DPE. Methods We retrospectively analyzed data prospectively collected from patients who underwent RAL for DPE at Tenon Hospital (Paris) between February 2019 and December 2024. Preoperative MRI staging was performed using the dPEI score, which stratifies DPE into mild (≤ 2), moderate (3–4), and severe (≥ 5). Surgical outcomes including operative time, hospital stay, postoperative complications using the Clavien–Dindo classification and voiding dysfunction were assessed. Results A hundred and seventy patients were included. Overall complication rate was 24.7%, including 7.7% Clavien–Dindo grade > II. De novo voiding dysfunction was observed in 10.6% of patients and persisted > 1 month in 4.1%. dPEI categories showed a positive correlation with longer operative time (Spearman’s ρ = 0.40, p < 0.001) and increased hospital stay (Spearman’s ρ = 0.43, p II complications (p = 0.02) and high incidence of voiding dysfunction (p = 0.01). Involvement of lateral compartments was associated with high operative time, hospital stay, and de novo voiding dysfunction. Conclusion Our results support the dPEI as a useful preoperative tool for predicting surgical outcomes after RAL for DPE. Its use can improve patient counseling, and shared decision-making, particularly in cases of severe disease (dPEI ≥ 5). Endometriosis robotic-assisted laparoscopy dPEI surgical outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Endometriosis is a frequent gynecological condition affecting up to 10% of women of reproductive age, although its true prevalence remains uncertain [ 1 ]. It is characterized by ectopic growth of tissue similar to the endometrium beyond the uterine cavity [ 2 ]. More recently, broader definitions have emerged to capture the systemic and multifactorial nature of endometriosis [ 3 ]. Endometriosis is a well-known etiology of chronic pelvic pain, dysuria, dyspareunia, digestive symptoms, and infertility impacting on quality of life [ 4 ]. DPE is thought to affect about 20% of women with endometriosis [ 5 , 6 ]. First-line management typically involves medical therapies such as analgesics, and hormonal suppression [ 7 ]. Surgical intervention is considered when medical treatment fails or when infertility or urinary or intestinal obstruction are present [ 8 – 10 ]. Surgical procedures should consists in complete removal of endometriotic tissue in order to maximize benefits and reduce the risk of recurrence [ 11 – 13 ]. Because these procedures are technically demanding and carry a risk of major complications such as urinary or rectovaginal fistulae [ 14 – 16 ], they should be restricted to experienced reference centers [ 17 ]. Several classification systems have been developed to aid preoperative evaluation and shared decision-making [ 18 ]. Although widely adopted in clinical and research settings, the revised ASRM classification remains limited as it mainly reflects the extent of superficial and ovarian disease, without adequately assessing deep endometriosis, thereby restricting its ability to guide surgical decision-making or predict functional outcomes (20–23). In 2021, the Enzian classification was proposed combining a complete staging of DPE with evaluation of peritoneal, ovarian, tubal locations, deep pelvic endometriosis lesions, and the presence of adenomyosis [ 19 , 20 ]. When evaluating the reproducibility of the Enzian classification applied to MRI, Manganaro and al (2021) reported an excellent inter-reader agreement for peritoneal, ovarian endometriosis and adenomyosis but a moderate concordance for DPE [ 21 ]. The dPEI was designed as an MRI-based framework for standardized evaluation of the extent of deep pelvic endometriosis. It divides the pelvis into central, lateral, and extra-pelvic regions, allowing a structured description of lesion location and severity. Based on the number of compartments involved, disease is categorized as mild (≤ 2), moderate (3–4), or severe (≥ 5) [ 22 ]. This tool was externally validated in a multicenter cohort, showing its value for predicting surgical complexity and postoperative outcomes, and thus for supporting patient counseling and surgical planning [ 23 ]. However, dPEI was evaluated in patients undergoing conventional laparoscopy rending the extrapolation to robotic assisted laparoscopy (RAL) questionable. Indeed, previous studies have underlined the contribution of RAL to improve the vision, the precision and optimized gestures with a potential decrease in intra- and postoperative complications including the decrease in the incidence of high stage complications according to the Clavien-Dindo classification, decrease of voiding dysfunction while increasing the rate of complete resection [ 24 , 25 ]. Therefore, the aims of the present study were to evaluate the relevance of the dPEI to predict operative time, postoperative complications, hospital stay, and voiding dysfunction after RAL for DPE. Material and Methods Population We retrospectively reviewed data prospectively gathered between February 2019 and December 2024 at the Tenon Hospital Endometriosis Expert Center (C3E, Sorbonne University, Paris). Informed consent was obtained from all individual participants included in the study. Surgical indications followed the European (ESHRE) and French national (HAS–CNGOF) guidelines, including women presenting with medical treatment failure, infertility, or digestive or urinary obstruction.[ 14 ]. A complete medical, surgical, and treatment history was obtained, followed by a physical examination. All patients underwent pelvic ultrasound and MRI, while rectal endoscopy and enterography MRI were performed when indicated. Decisions for surgery were systematically validated by a multidisciplinary committee. Patients eligible for inclusion had a complete DPE resection by RAL and had undergone MRI within the past year. Institutional review board approval was obtained (CEROG 2023-GYN-09-02). MRI protocol MRI protocol All pelvic MRIs were acquired at 1.5 T or 3 T with a phased-array coil, following a high-resolution protocol (T2- and T1-weighted sequences with and without fat suppression). Gadolinium was administered only when clinically indicated, in accordance with French HAS–CNGOF recommendations [ 23 , 26 ]. An experienced radiologist (SM), unaware of the patients’ clinical and surgical information, independently reviewed all MRI images. Endometriosis lesions were classified according to the dPEI framework, which divides the pelvis into nine anatomical compartments—anterior, middle, and posterior regions, each with central and lateral subdivisions—plus an optional category for extra-pelvic disease [ 23 ]. For each affected compartment, one point was assigned, with an additional point given if the disease extended laterally beyond the parietal fascia. The DPE lesions were reported as belonging to 1 of the 10 compartments. In the presence of substantial tethering and anatomic distortion due to severe DPE causing projection of a structure into a different compartment, the compartment of the initial location was considered the involved structure [ 22 ]. Finally, a dPEI score was determined in accordance with the previous study [ 23 ]. The cumulative score defines the severity group : mild (≤ 2), moderate (3–4), or severe (≥ 5). S urgical procedures and outcomes Intraoperative staging of endometriosis was performed using the revised American Society for Reproductive Medicine (rASRM) classification system [ 27 ]. Robotic-assisted procedures were carried out with the Da Vinci Xi following previously published protocols [ 25 ]. Depending on disease extent, surgery could include adnexal operations, uterosacral or parametrial resection, partial colpectomy, ureterolysis, cystectomy, hysterectomy, or bowel surgery such as shaving, discoid, or segmental resection. All operations were conducted by senior surgeons (CT, YD, CF, ED), each with more than five years’ experience in endometriosis surgery. These surgeons had equivalent access to conventional laparoscopy and RAL. The choice between robotic and conventional laparoscopy depended on both RAL availability and surgeon preference. For RAL, an 8 mm trocar was placed trans-umbilically for the optics. On the same horizontal line, a 12- or 8-mm trocar was placed on the right for an ultrasonic energy scalpel, monopolar scissors or automatic stapling forceps and an additional 8 mm trocar on the right flank for a grasping forceps. On the left, an 8 mm trocar was placed for the bipolar forceps and a 5 mm conventional trocar for the operating aid [ 28 ]. A temporary protective stoma was created only when colorectal resection with associated colpectomy precluded safe interposition of peritoneal or mesorectal tissue between the vaginal and bowel anastomosis. Surgical outcomes included the evaluation of operative time, hospital stay, urinary, digestive, vascular complications, and reoperations. The complications were stratified according to the Clavien-Dindo classification as low grade (I-II) or high grade (III-IV) during the post operative hospitalization and late up to the first postoperative month. Statistical analysis Data were recorded in Microsoft Excel, and statistical analyses were conducted using Student’s t -tests for continuous variables and Chi-square tests for categorical variables. Associations between continuous variables were explored using Pearson’s correlation coefficient, and logistic regression models were applied for multivariate analyses. All statistical computations were carried out using R software (version 2.15.2; RStudio, Boston, MA, USA). A p -value < 0.05 was considered statistically significant. Results Epidemiologic characteristics of the study population. A total of 170 patients were included on between February 2019 and December 2024. The epidemiologic characteristics of the study population are summarized in the Table 1 . The median patient age was 36 years old ,with most being nulliparous. Among the 157 patients with prior surgery, 70 patients (44.5%) had a history of gynecological surgery. The main symptoms reported by the patients were dysmenorrhea (87%), dyspareunia (70%), and chronic pelvic pain (48%). All the patients had multiple symptoms suggestive of endometriosis. Table 1 Characteristics of women with DPE undergoing surgery (N = 170) Clinical symptoms Number of patients (%) Chronic pelvic pain 81 (48) Dysménorrhea 148 (87) Dyspareunia 119 (70) Defecation pain 57 (33) Dyschesia 41 (24) Dysuria 55 (32) Menorraghia 13 (7) Epidemiologic characteristics Median age (years) [Q1-Q3] 36 [ 31 – 43 ] Median BMI (kg/m²) [Q1-Q3] 25.5 [21.4–29.2] Smoking 35 (20.6) History of abdominal surgery 53 (31.2) History of endometriosis surgery 34 (20) History of gynecologic surgery 70 (58.3) • Nulliparous • Uniparous • Multiparous 96 (56) 27 (16) 48 (28) Hormonal treatment before surgery 102 (60) Infertility 56 (33) Surgical procedures and intra- and postoperative complications Surgical procedures and complications according to compartment involved by endometriosis are summarized in the Table 2 . The median operative time and hospital stay were 181 min (± 95.3) and 4.5 days (± 4.1), respectively. Colorectal surgery was the most frequent intervention, performed in 141 patients (82.9%), encompassing 54 discoid excisions, 44 rectal shavings, and 43 segmental resections. Conversion to open surgery occurred in 2.9% of cases. The rate of digestive stoma was 5.9%. Postoperative complications were absent in 128 patients (75.3%). Among the remaining 42 patients (24.7%), the distribution of the postoperative complications according to the Clavien-Dindo classification was 69% with grade II (29 patients), 23.8% with grade III (10 patients), 1.8% with grade IV (3 patients), and no patient underwent a grade V complication. The overall rate of de novo voiding dysfunction was 10.6% (18 patients) and the rate of voiding dysfunction beyond one month was 4.1% (7 patients). MRI findings All patients underwent a preoperative MRI, performed within one year prior to surgery, as well as a dPEI evaluation. The distribution of the compartments involved by endometriosis is reported in the Table 2 . The mediocentral (91.8%), posterocentral (59.4%), and mediolateral (47.1%) compartments were most commonly affected. Interestingly, 11.8% of the patients had extrapelvic endometriosis. According to dPEI categories, 37.7% had mild, 37.6% moderate, and 24.7% severe endometriosis. Table 2 Surgical outcomes with dPEI MRI description (N = 170) Compartment involved by endometriosis Number of patients with compartment involved (%) Number of patients without endometriosis (%) P value Mediocentral No. of patients (%) 156 (91.8) 14 (8.2) NA Operative time,médian (IQR), min 195 (136–251) 129 (100–165) 0.007 Hospital stay,median (IQR),d 5 (2–7) 2 (1–5) 0.04 CD grade > II,No.(%) 12 (7.7) 1 (7.1) 1 De novo voiding dysfunction,No. (%) 17 (10.9) 1 (7.1) 0.86 De novo voiding dysfunction lasting > 1 month, No.(%) 6 (3.8) 1 (7.1) 0.56 Posterocentral No. of patients (%) 101 (59.4) 69 (40.6) NA Operative time,médian (IQR), min 220 (180–280) 136 (92–191) < 0.001 Hospital stay,median (IQR),d 5 (3–7) 2 (1–5) II,No.(%) 10 (9.9) 3 (4.3) 0.30 De novo voiding dysfunction,No. (%) 12 (12.0) 6 (8.7) 0.56 De novo voiding dysfunction lasting > 1 month,No.(%) 5 (4.9) 2 (2.9) 0.56 Anterocentral No. of patients (%) 19 (11.2) 151 (88.8) NA Operative time,médian (IQR), min 220 (146–330) 180 (124–240) 0.22 Hospital stay,median (IQR),d 6 (3-8.5) 4 (2–6) 0.12 CD grade > II,No.(%) 1 (5.3) 12 (7.9) 0.12 De novo voiding dysfunction,No. (%) 2 (10.5) 16 (10.6) 0.94 De novo voiding dysfunction lasting > 1 month, No.(%) 1 (5.3) 6 (4.0) 0.53 Mediolateral No. of patients (%) 80 (47.1) 90 (52.9) NA Operative time,médian (IQR), min 212 (180–296) 155 (102–231) < 0.001 Hospital stay,median (IQR),d 5 (4–7) 3 (2–6) II,No.(%) 8 (10.0) 5 (5.5) 0.42 De novo voiding dysfunction,No. (%) 13 (16.2) 5 (5.5) 0.04 De novo voiding dysfunction lasting > 1 month, No.(%) 5 (6.2) 2 (2.2) 0.04 Posterolateral No. of patients (%) 51 (30.0) 119 (70.0) NA Operative time,médian (IQR), min 230 (142–295) 180 (124–240) 0.03 Hospital stay,median (IQR),d 5.5 (4–8) 3 (2–6) II,No.(%) 7 (13.7) 6 (5.0) 0.10 De novo voiding dysfunction,No. (%) 13 (25.4) 5 (4.2) 1 month, No.(%) 4 (7.8) 3 (2.5) 0.25 Anterolateral No. of patients (%) 4 (2.4) 166 (97.6) NA Operative time,médian (IQR), min 142 (110–208) 184 (129–244) 0.47 Hospital stay,median (IQR),d 2 (1.8–4.8) 5 (2–6) 0.39 CD grade > II,No.(%) 0 13 (7.8) 1 De novo voiding dysfunction,No. (%) 0 18 (10.8) 0.77 De novo voiding dysfunction lasting > 1 month,No. (%) 0 7 (4.2) 0.81 Extrapelvic No. of patients (%) 20 (11.8) 150 (88.2) NA Operative time,médian (IQR), min 240 (176–285) 180 (120–240) 0.03 Hospital stay,median (IQR),d 6 (5–7) 4 (2–6) 0.04 CD grade > II 1 (5.0) 12 (8.0) 0.98 De novo voiding dysfunction 0 18 (12.0) 0.24 De novo voiding dysfunction lasting > 1 month,No. (%) 0 7 (4.7) 0.31 Relation between pelvic compartment involvement or dPEI score and surgical outcomes The distribution of operative time, complication rate according to the Clavien-Dindo classification, and hospital stay according to the pelvic compartment involved by endometriosis is summarized in the Table 2 . Mediocentral compartment was associated with a higher operative time (p = 0.007), a longer hospital stays (p = 0.04), but without increased incidence of grade III complication neither in the rate of voiding dysfunction. Posterocentral compartment was associated with a higher operative time (p < 0.001), a longer hospital stays (p < 0.001), but without increased incidence of grade III complication neither in the rate of voiding dysfunction. Anterocentral compartment was not associated with an increase in operative time, hospital stay, grade III complication, nor in voiding dysfunction. Mediolateral compartment was associated with a higher operative time (p < 0.001), a longer hospital stays (p < 0.001), a trend for a higher incidence of voiding dysfunction (p = 0.05), but without increased incidence of grade III complication. Posterolateral compartment was associated with a higher operative time (p = 0.03), a longer hospital stays (p < 0.001), a higher incidence of voiding dysfunction (p < 0.001), and a trend for in increased incidence of grade III complication (p = 0.1). The number of patients with involvement of the anterolateral compartment was too low to evaluate its impact on operative time, hospital stay, incidence of grade III complication nor on voiding dysfunction. Extrapelvic endometriosis was associated with a higher operative time (p = 0.02), a longer hospital stays (p = 0.04), but without increased incidence of grade III complication neither in the rate of voiding dysfunction. Operative time significantly increased with higher dPEI categories: 140 min (mild), 202 min (moderate), and 240 min (severe) ( p < 0.001). This trend showed a positive correlation (Spearman ρ = 0.40, p < 0.001) (Fig. 1 ). Similarly, length hospital stay was associated with the dPEI category score, with an increase in median length of hospital stays: 3 days ,5 days and 6 days respectively for mild, moderate and severe endometriosis, respectively (p < 0.01). The difference was significant regardless of the groups of dPEI compared, with a positive correlation (Spearman’s ρ = 0.43, p < 0.001) (Fig. 2). The frequency of severe complications rose with the severity of the dPEI: 1.6% for mild, 7.8% for moderate, and 16.7% for severe cases ( p = 0.02). Severe complications occurred more frequently in patients with severe endometriosis compared with patients with mild endometriosis (OR = 13.1; 95% CI [1.54–111.3]). De novo voiding dysfunction occurred in 4.7%, 7.8%, and 23.8% of mild, moderate, and severe dPEI categories, respectively ( p = 0.01). Voiding dysfunction occurred more frequently in patients with severe endometriosis compared with patients with mild endometriosis (OR = 5.9; 95% CI [1.48–23.5]). Discussion This retrospective study confirms that the dPEI, initially validated for laparoscopic surgery, can also predict postoperative risk when applied to RAL for DPE. In the current study, RAL was primarily selected for patients presenting with severe disease according to the dPEI classification. In contrast to the multicenter external validation, where only 13.1% of patients had a dPEI ≥ 5, severe cases represented nearly one quarter of our series representing a potential bias to adequately evaluate the complication risk for this specific subpopulation. The prior validation study did not stratify outcomes by surgical approach, likely due to the predominant use of conventional laparoscopy. This limitation prevented extrapolation to RAL, although previous studies and meta-analyses have shown reduced hospital stay and postoperative complications, likely owing to better visualization and nerve identification with the robotic system, albeit at the cost of increased operative time [ 14 , 24 , 28 – 30 ]. In our study, when considering the pelvic compartments, the mediocentral and the postrocentral compartments were the most frequently involved in 91.8% and 59.4%, respectively. Interestingly, the mediolateral compartment, defined by the involvement of parametrium, ureteral dilatation, and pelvic wall, and the posterolateral compartment, defined by the involvement of distal portion of uterosacral ligaments, sacrorectal septum, and pelvic wall were involved in 47.1% and 30% respectively. This also contrast with the multicenter external validation of the dPEI where the mediolateral compartment involvement was noted in only 21.6%. This difference is crucial as lateral compartments are well recognized to be associated with the risks of ureteral, vascular and nervous injuries with a higher risk of voiding dysfunction [ 31 – 34 ]. In the present study, when comparing patients according to dPEI score categories, an increase in operative time, hospital stay, incidence of grade III complications according to the Clavien-Dindo classification was observed from mild to severe endometriosis (p < 0.001). A positive correlation was found with longer operative time (Spearman’s ρ = 0.40) and hospital stay (Spearman’s ρ = 0.43). The increment in operative time, hospital stay, and complication rate observed in our series aligns with findings from the multicenter external validation of the dPEI [ 23 ]. These data support the relevance of the dPEI scoring system as a predictive tool of surgical outcomes after RAL for DPE thus contributing to improve decision making. To date, only a few tools can be used to tailor preoperative counseling for women with DPE. Poupon and al. proposed a nomogram for predicting complication risk in deep endometriosis without bowel involvement but its discriminative performance remained modest (AUC = 0.72) [ 35 ]. Bazot et al. introduced the Endostage MRI classification, which aims to correlate the anatomical spread of lesions with surgical difficulty, although it still awaits multicenter validation [ 36 ]. Overall, 10.6% of patients developed de novo voiding dysfunction, rising to 23.8% among those with severe endometriosis—mostly associated with medolateral and posterolateral compartments involvement. Moreover, when considering the duration of voiding dysfunction inferior or superior to one postoperative month for the whole population, the rates were 10.6% and 4.1%, respectively supporting that about two-thirds of the patients recovered normal micturition in the first postoperative month. In contrast, in the dPEI multicenter external validation, the occurrence of a voiding dysfunction was observed in only 7.4% of the whole population and was considered a grade II complication while this complication is not included in the Clavien-Dindo classification. The higher rate of urinary dysfunction observed here may relate to the substantial proportion of colorectal resections, a known risk factor for postoperative voiding disorders [ 15 , 16 , 33 , 37 , 38 ]. Transient (< 1 month) voiding dysfunction may be considered minor, whereas persistence beyond one month reflects a severe complication that substantially affects quality of life and may require neuromodulation therapy [ 15 , 32 , 39 – 44 ]. In addition, a previous meta-analysis on colorectal resection for endometriosis has emphasized that the rate of voiding dysfunction depended on the type of colorectal surgery. Indeed, rectal shaving was less associated with voiding dysfunction than segmental colorectal resection (OR : 0.34; CI : 0.18–0.63, p < 0.001) or discoid excision (OR : 0.22; CI : 0.09–0.51, p < 0.001) while no difference was found between discoid and segmental surgery [ 15 ]. In our study, among the 150 patients with colorectal surgery (88% of the whole population), only 17.3% underwent a rectal shaving while the remaining patients underwent discoid excision or segmental resection. Moreover, previous studies have underlined the high rate of voiding dysfunction in case of vaginal and/or parametrial endometriosis that were required respectively in 22% and 41% of our patients [ 32 , 33 , 37 ]. Finally, in our study, when considering complications rates according to compartments involved, no differences between patients with a mediolateral and posterolateral compartment endometriosis were observed. This study has several limitations that warrant consideration. First, its retrospective design limits the ability to exclude residual biases. Second, no attempt was made to evaluate among patients with a severe dPEI whether the risk of complication varied according to the type of colorectal surgery (rectal shaving, discoid excision and segmental resection). Third, no attempt was done to evaluate the predictive value of 4th postoperative day CRP in the detection of complication after colorectal surgery for endometriosis [ 45 ]. However, our rates of pelvic abscess and of rectovaginal fistulae (0.04% and 0.006%, respectively) were too low to allow a statistical evaluation. Lastly, the study did not include a cost-effectiveness analysis to determine whether the dPEI could serve as a practical selection tool for robotic surgery. The dPEI proved to be a reliable MRI-based index for predicting postoperative outcomes in patients undergoing RAL for DPE. Applying this index preoperatively may enhance patient counseling and multidisciplinary decision-making, particularly for individuals with extensive disease (dPEI ≥ 5). Future prospective studies are warranted to determine whether the robotic approach can effectively reduce the incidence of postoperative voiding dysfunction. Finally, in the absence of solid evidence demonstrating the cost-effectiveness of robotic surgery, the dPEI could help identify patients with severe forms of endometriosis who might derive the greatest benefit from a robotic approach. Declarations Autor’s roles All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AR and SM. The statistics were performed by MF and CF. The first draft of the manuscript was written by AR and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The final draft was validated by ED et IT. Conflict of interest: Yohann Dabi, Meryl Dahan, Clément Ferrier, Cyril Touboul, Emile Daraï, Shiwa Mansournia, Marie Florin and Isabelle Thomassin-Naggara have no conflict of interest to disclose. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AR and SM. The statistics were performed by MF and CF. The first draft of the manuscript was written by AR and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The final draft was validated by ED et IT. Data Availability The datasets analyzed during the current study are not publicly available due to patient privacy and institutional data protection policies at Tenon Hospital (Paris, France). However, anonymized data supporting the findings of this study are available from the corresponding author. 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Hum Reprod. 1 juin. ;28(6):1552–68 Maciel C, Ferreira H, Djokovic D, Kyaw Tun J, Keckstein J, Rizzo S, Manganaro L (2023) MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report. Insights Imaging 5 juill 14(1):120 Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, Krentel H, Janschek E, Exacoustos C, Malzoni M, Mueller M, Roman H, Condous G, Forman A, Jansen FW, Bokor A, Simedrea V, Hudelist G (2021) The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand juill 100(7):1165–1175 Manganaro L, Celli V, Dolciami M, Ninkova R, Ercolani G, Ciulla S, De Vito C, Rizzo SM, Porpora MG, Catalano C (sept 2021) Can New ENZIAN Score 2020 Represent a Staging System Improving MRI Structured Report? Int J Environ Res Public Health 22(19):9949 Thomassin-Naggara I, Lamrabet S, Crestani A, Bekhouche A, Wahab CA, Kermarrec E, Touboul C, Daraï E (2020) Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management. Hum Reprod 1 juill 35(7):1589–1600 Thomassin-Naggara I, Monroc M, Chauveau B, Fauconnier A, Verpillat P, Dabi Y, Gavrel M, Bolze PA, Darai E, Touboul C, Lamrabet S, Collinet P, Zareski E, Bourdel N, Roman H, Rousset P (2023) Multicenter External Validation of the Deep Pelvic Endometriosis Index Magnetic Resonance Imaging Score. JAMA Netw Open. 4 mai. ;6(5):e2311686 Pavone M, Baroni A, Campolo F, Goglia M, Raimondo D, Carcagnì A, Akladios C, Marescaux J, Fanfani F, Scambia G, Ianieri MM (2024) Robotic assisted versus laparoscopic surgery for deep endometriosis: a meta-analysis of current evidence. J Robot Surg. 16 mai. ;18(1):212 Ferrier C, Le Gac M, Kolanska K, Boudy AS, Dabi Y, Touboul C, Bendifallah S, Daraï E (2022) Comparison of robot-assisted and conventional laparoscopy for colorectal surgery for endometriosis: A prospective cohort study. Int J Med Robot Comput Assist Surg MRCAS juin 18(3):e2382 Christine RD (2025) Actualisation de la place des différents examens d’imagerie pour le diagnostic d’endométriose American Society For Reproductive Medicine (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril mai 67(5):817–821 Le Gac M, Ferrier C, Touboul C, Owen C, Arfi A, Boudy AS, Jayot A, Bendifallah S, Daraï E Comparison of robotic versus conventional laparoscopy for the treatment of colorectal endometriosis: Pilot study of an expert center. J Gynecol Obstet Hum Reprod. 29 juill 2020;101885. 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Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet déc 167(3):1043–1054 Poupon C, Owen C, Arfi A, Cohen J, Bendifallah S, Daraï E (2019) Nomogram predicting the likelihood of complications after surgery for deep endometriosis without bowel involvement. Eur J Obstet Gynecol Reprod Biol X juill 3:100028 Bazot M, Daraï E, Benagiano GP, Reinhold C, Favier A, Roman H, Donnez J, Bendifallah S (2022) ENDO_STAGE Magnetic Resonance Imaging: Classification to Screen Endometriosis. J Clin Med. 26 avr. ;11(9):2443 Partial colpectomy is a risk factor for urologic complications of colorectal resection for endometriosis - PubMed [Internet]. [cité 20 sept 2025]. Disponible sur: https://pubmed.ncbi.nlm.nih.gov/23131702/ Madar A, Crestani A, Eraud P, Spiers A, Constantin A, Chiche F, Furet E, Collinet P, Touboul C, Merlot B, Roman H, Dabi Y, Bendifallah S (2025) Voiding dysfunction after surgery for colorectal deep infiltrating endometriosis: an updated systematic review and meta-analysis. Updat Surg 1 juin 77(3):739–748 Nyangoh Timoh K, Canlorbe G, Verollet D, Peyrat L, Ballester M, Amarenco G, Darai E (2015) Contribution of sacral neuromodulation to manage persistent voiding dysfunction after surgery for deep infiltrating endometriosis with colorectal involvement: preliminary results. Eur J Obstet Gynecol Reprod Biol juill 190:31–35 Agnello M, Vottero M, Bertapelle P (2021) Sacral neuromodulation to treat voiding dysfunction in patients with previous pelvic surgery for deep infiltrating endometriosis: our centre’s experience. Int Urogynecol J juin 32(6):1499–1504 Ballester M, Dubernard G, Wafo E, Bellon L, Amarenco G, Belghiti J, Daraï E (2014) Evaluation of urinary dysfunction by urodynamic tests, electromyography and quality of life questionnaire before and after surgery for deep infiltrating endometriosis. Eur J Obstet Gynecol Reprod Biol août 179:135–140 Turco LC, Tortorella L, Tuscano A, Palumbo MA, Fagotti A, Uccella S, Fanfani F, Ferrandina G, Nicolotti N, Vargiu V, Lodoli C, Scaldaferri F, Scambia G, Cosentino F (2020) Surgery-related complications and long-term functional morbidity after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT morb). Arch Gynecol Obstet oct 302(4):983–993 Morelli L, Perutelli A, Palmeri M, Guadagni S, Mariniello MD, Di Franco G, Cela V, Brundu B, Salerno MG, Di Candio G, Mosca F (2016) Robot-assisted surgery for the radical treatment of deep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and functional outcomes. Int J Colorectal Dis mars 31(3):643–652 Grouin A, Florian A, Sans Mischel AC, Toullalan O (2018) [Detrusor sphincter disorders associated with deep endometriosis: Systematic review of the literature]. Progres En Urol J Assoc Francaise Urol Soc Francaise Urol janv 28(1):2–11 Pécheux O, Dilé P, Kerbage Y, Piessen G, Deken V, Collinet P, Rubod C (2021) Predictive value of 4th post-operative-day CRP in the early detection of complications after laparoscopic bowel resection for endometriosis. J Gynecol Obstet Hum Reprod 1 nov 50(9):102148 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 02 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviewers agreed at journal 02 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviewers agreed at journal 02 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers invited by journal 30 Oct, 2025 Editor assigned by journal 30 Oct, 2025 Submission checks completed at journal 30 Oct, 2025 First submitted to journal 30 Oct, 2025 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. 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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-7988692","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":538910154,"identity":"d9d7150e-59c9-4326-926f-52fec507acfa","order_by":0,"name":"Adèle 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08:47:15","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":142037,"visible":true,"origin":"","legend":"","description":"","filename":"7f5d33622ef6437d80fd7574e1551dde1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/0c55c0849b9902bd0568c895.xml"},{"id":95806106,"identity":"997a353a-91d6-412f-805f-e15bee3bc95e","added_by":"auto","created_at":"2025-11-13 08:47:16","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":153498,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/e06d400c9bcb54ea209d657f.html"},{"id":95805924,"identity":"d799c462-46b5-48c3-9a77-b0b3bd4bb952","added_by":"auto","created_at":"2025-11-13 08:47:06","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":248002,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOperative time according to dPEI categories score (p\u0026lt;0,001;\u003c/em\u003eSpearman’s ρ = 0.40)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/e9ee0683b6f4ce73c83439a7.jpeg"},{"id":95805832,"identity":"7a4ab5cd-3b9a-4793-b5dd-33314aaf0e11","added_by":"auto","created_at":"2025-11-13 08:46:57","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":189172,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eHospital say according to dPEI categories score in days (p\u0026lt;0.001;\u003c/em\u003eSpearman’s ρ = 0.43)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/7ed353f11445e23e4fdc0fad.jpeg"},{"id":95805960,"identity":"be928044-1141-4c77-9538-9677a3cf3aa4","added_by":"auto","created_at":"2025-11-13 08:47:10","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":196278,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eClavien-Dindo\u0026gt;II according to dPEI categories score (p=0.02)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/3ee4e7fe549a375c1c80ab54.jpeg"},{"id":95805972,"identity":"4aa371ea-13ac-4ace-9651-3d986443c962","added_by":"auto","created_at":"2025-11-13 08:47:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":137457,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRate of de novo voiding dysfunction according dPEI score categories (p=0.01)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/04284d5be543de33495594f5.png"},{"id":101151736,"identity":"a216985c-f8cc-4ef0-bbd3-0d7eaddf4b12","added_by":"auto","created_at":"2026-01-26 16:03:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1694724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7988692/v1/ab1a3f18-29e9-41ae-8685-a7c5ea4dc5b9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eValidation of the Deep Pelvis Endometriosis Index (dPEI) to evaluate surgical outcomes of robotic-assisted surgery for endometriosis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a frequent gynecological condition affecting up to 10% of women of reproductive age, although its true prevalence remains uncertain [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is characterized by ectopic growth of tissue similar to the endometrium beyond the uterine cavity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. More recently, broader definitions have emerged to capture the systemic and multifactorial nature of endometriosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Endometriosis is a well-known etiology of chronic pelvic pain, dysuria, dyspareunia, digestive symptoms, and infertility impacting on quality of life [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. DPE is thought to affect about 20% of women with endometriosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFirst-line management typically involves medical therapies such as analgesics, and hormonal suppression [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgical intervention is considered when medical treatment fails or when infertility or urinary or intestinal obstruction are present [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Surgical procedures should consists in complete removal of endometriotic tissue in order to maximize benefits and reduce the risk of recurrence [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Because these procedures are technically demanding and carry a risk of major complications such as urinary or rectovaginal fistulae [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], they should be restricted to experienced reference centers [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral classification systems have been developed to aid preoperative evaluation and shared decision-making [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although widely adopted in clinical and research settings, the revised ASRM classification remains limited as it mainly reflects the extent of superficial and ovarian disease, without adequately assessing deep endometriosis, thereby restricting its ability to guide surgical decision-making or predict functional outcomes (20\u0026ndash;23). In 2021, the Enzian classification was proposed combining a complete staging of DPE with evaluation of peritoneal, ovarian, tubal locations, deep pelvic endometriosis lesions, and the presence of adenomyosis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. When evaluating the reproducibility of the Enzian classification applied to MRI, Manganaro and al (2021) reported an excellent inter-reader agreement for peritoneal, ovarian endometriosis and adenomyosis but a moderate concordance for DPE [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The dPEI was designed as an MRI-based framework for standardized evaluation of the extent of deep pelvic endometriosis. It divides the pelvis into central, lateral, and extra-pelvic regions, allowing a structured description of lesion location and severity. Based on the number of compartments involved, disease is categorized as mild (\u0026le;\u0026thinsp;2), moderate (3\u0026ndash;4), or severe (\u0026ge;\u0026thinsp;5) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This tool was externally validated in a multicenter cohort, showing its value for predicting surgical complexity and postoperative outcomes, and thus for supporting patient counseling and surgical planning [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, dPEI was evaluated in patients undergoing conventional laparoscopy rending the extrapolation to robotic assisted laparoscopy (RAL) questionable. Indeed, previous studies have underlined the contribution of RAL to improve the vision, the precision and optimized gestures with a potential decrease in intra- and postoperative complications including the decrease in the incidence of high stage complications according to the Clavien-Dindo classification, decrease of voiding dysfunction while increasing the rate of complete resection [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, the aims of the present study were to evaluate the relevance of the dPEI to predict operative time, postoperative complications, hospital stay, and voiding dysfunction after RAL for DPE.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePopulation\u003c/h2\u003e\u003cp\u003e We retrospectively reviewed data prospectively gathered between February 2019 and December 2024 at the Tenon Hospital Endometriosis Expert Center (C3E, Sorbonne University, Paris). Informed consent was obtained from all individual participants included in the study. Surgical indications followed the European (ESHRE) and French national (HAS\u0026ndash;CNGOF) guidelines, including women presenting with medical treatment failure, infertility, or digestive or urinary obstruction.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A complete medical, surgical, and treatment history was obtained, followed by a physical examination. All patients underwent pelvic ultrasound and MRI, while rectal endoscopy and enterography MRI were performed when indicated. Decisions for surgery were systematically validated by a multidisciplinary committee. Patients eligible for inclusion had a complete DPE resection by RAL and had undergone MRI within the past year. Institutional review board approval was obtained (CEROG 2023-GYN-09-02).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMRI protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eMRI protocol\u003c/div\u003e\u003cp\u003eAll pelvic MRIs were acquired at 1.5 T or 3 T with a phased-array coil, following a high-resolution protocol (T2- and T1-weighted sequences with and without fat suppression). Gadolinium was administered only when clinically indicated, in accordance with French HAS\u0026ndash;CNGOF recommendations [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. An experienced radiologist (SM), unaware of the patients\u0026rsquo; clinical and surgical information, independently reviewed all MRI images.\u003c/p\u003e\u003cp\u003eEndometriosis lesions were classified according to the dPEI framework, which divides the pelvis into nine anatomical compartments\u0026mdash;anterior, middle, and posterior regions, each with central and lateral subdivisions\u0026mdash;plus an optional category for extra-pelvic disease [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. For each affected compartment, one point was assigned, with an additional point given if the disease extended laterally beyond the parietal fascia. The DPE lesions were reported as belonging to 1 of the 10 compartments. In the presence of substantial tethering and anatomic distortion due to severe DPE causing projection of a structure into a different compartment, the compartment of the initial location was considered the involved structure [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Finally, a dPEI score was determined in accordance with the previous study [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The cumulative score defines the severity group : mild (\u0026le;\u0026thinsp;2), moderate (3\u0026ndash;4), or severe (\u0026ge;\u0026thinsp;5).\u003c/p\u003e\u003cp\u003e\u003cb\u003eS\u003c/b\u003e\u003cb\u003eurgical procedures and outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIntraoperative staging of endometriosis was performed using the revised American Society for Reproductive Medicine (rASRM) classification system [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Robotic-assisted procedures were carried out with the Da Vinci Xi following previously published protocols [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Depending on disease extent, surgery could include adnexal operations, uterosacral or parametrial resection, partial colpectomy, ureterolysis, cystectomy, hysterectomy, or bowel surgery such as shaving, discoid, or segmental resection.\u003c/p\u003e\u003cp\u003eAll operations were conducted by senior surgeons (CT, YD, CF, ED), each with more than five years\u0026rsquo; experience in endometriosis surgery. These surgeons had equivalent access to conventional laparoscopy and RAL. The choice between robotic and conventional laparoscopy depended on both RAL availability and surgeon preference. For RAL, an 8 mm trocar was placed trans-umbilically for the optics. On the same horizontal line, a 12- or 8-mm trocar was placed on the right for an ultrasonic energy scalpel, monopolar scissors or automatic stapling forceps and an additional 8 mm trocar on the right flank for a grasping forceps. On the left, an 8 mm trocar was placed for the bipolar forceps and a 5 mm conventional trocar for the operating aid [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A temporary protective stoma was created only when colorectal resection with associated colpectomy precluded safe interposition of peritoneal or mesorectal tissue between the vaginal and bowel anastomosis.\u003c/p\u003e\u003cp\u003eSurgical outcomes included the evaluation of operative time, hospital stay, urinary, digestive, vascular complications, and reoperations. The complications were stratified according to the Clavien-Dindo classification as low grade (I-II) or high grade (III-IV) during the post operative hospitalization and late up to the first postoperative month.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData were recorded in Microsoft Excel, and statistical analyses were conducted using Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-tests for continuous variables and Chi-square tests for categorical variables. Associations between continuous variables were explored using Pearson\u0026rsquo;s correlation coefficient, and logistic regression models were applied for multivariate analyses. All statistical computations were carried out using R software (version 2.15.2; RStudio, Boston, MA, USA). A \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eEpidemiologic characteristics of the study population.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 170 patients were included on between February 2019 and December 2024.\u003c/p\u003e\u003cp\u003eThe epidemiologic characteristics of the study population are summarized in the Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The median patient age was 36 years old ,with most being nulliparous. Among the 157 patients with prior surgery, 70 patients (44.5%) had a history of gynecological surgery. The main symptoms reported by the patients were dysmenorrhea (87%), dyspareunia (70%), and chronic pelvic pain (48%). All the patients had multiple symptoms suggestive of endometriosis.\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\u003eCharacteristics of women with DPE undergoing surgery (N\u0026thinsp;=\u0026thinsp;170)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical symptoms\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic pelvic pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81 (48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDysm\u0026eacute;norrhea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148 (87)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDyspareunia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119 (70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDefecation pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57 (33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDyschesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (24)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDysuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55 (32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMenorraghia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEpidemiologic characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian age (years) [Q1-Q3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 [\u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian BMI (kg/m\u0026sup2;) [Q1-Q3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.5 [21.4\u0026ndash;29.2]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (20.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of abdominal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (31.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of endometriosis surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of gynecologic surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70 (58.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Nulliparous\u003c/p\u003e\u003cp\u003e\u0026bull; Uniparous\u003c/p\u003e\u003cp\u003e\u0026bull; Multiparous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96 (56)\u003c/p\u003e\u003cp\u003e27 (16)\u003c/p\u003e\u003cp\u003e48 (28)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHormonal treatment before surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e102 (60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfertility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56 (33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eSurgical procedures and intra- and postoperative complications\u003c/h3\u003e\n\u003cp\u003eSurgical procedures and complications according to compartment involved by endometriosis are summarized in the Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median operative time and hospital stay were 181 min (\u0026plusmn;\u0026thinsp;95.3) and 4.5 days (\u0026plusmn;\u0026thinsp;4.1), respectively. Colorectal surgery was the most frequent intervention, performed in 141 patients (82.9%), encompassing 54 discoid excisions, 44 rectal shavings, and 43 segmental resections. Conversion to open surgery occurred in 2.9% of cases. The rate of digestive stoma was 5.9%. Postoperative complications were absent in 128 patients (75.3%). Among the remaining 42 patients (24.7%), the distribution of the postoperative complications according to the Clavien-Dindo classification was 69% with grade II (29 patients), 23.8% with grade III (10 patients), 1.8% with grade IV (3 patients), and no patient underwent a grade V complication.\u003c/p\u003e\u003cp\u003eThe overall rate of de novo voiding dysfunction was 10.6% (18 patients) and the rate of voiding dysfunction beyond one month was 4.1% (7 patients).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eMRI findings\u003c/h2\u003e\u003cp\u003eAll patients underwent a preoperative MRI, performed within one year prior to surgery, as well as a dPEI evaluation. The distribution of the compartments involved by endometriosis is reported in the Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The mediocentral (91.8%), posterocentral (59.4%), and mediolateral (47.1%) compartments were most commonly affected. Interestingly, 11.8% of the patients had extrapelvic endometriosis.\u003c/p\u003e\u003cp\u003eAccording to dPEI categories, 37.7% had mild, 37.6% moderate, and 24.7% severe endometriosis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical outcomes with dPEI MRI description (N\u0026thinsp;=\u0026thinsp;170)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" 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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompartment involved by endometriosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients with compartment involved (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of patients without endometriosis (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMediocentral\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e156 (91.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (8.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e195 (136\u0026ndash;251)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129 (100\u0026ndash;165)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (2\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (10.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month, No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePosterocentral\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101 (59.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (40.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e220 (180\u0026ndash;280)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e136 (92\u0026ndash;191)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnterocentral\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e151 (88.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e220 (146\u0026ndash;330)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180 (124\u0026ndash;240)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3-8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (7.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month, No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMediolateral\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80 (47.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90 (52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e212 (180\u0026ndash;296)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e155 (102\u0026ndash;231)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (4\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month, No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePosterolateral\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51 (30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e119 (70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e230 (142\u0026ndash;295)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180 (124\u0026ndash;240)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.5 (4\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (25.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month, No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnterolateral\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e166 (97.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e142 (110\u0026ndash;208)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e184 (129\u0026ndash;244)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.8\u0026ndash;4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II,No.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (10.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExtrapelvic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e150 (88.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time,m\u0026eacute;dian (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e240 (176\u0026ndash;285)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180 (120\u0026ndash;240)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay,median (IQR),d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (5\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD grade\u0026thinsp;\u0026gt;\u0026thinsp;II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe novo voiding dysfunction lasting\u0026thinsp;\u0026gt;\u0026thinsp;1 month,No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRelation between pelvic compartment involvement or dPEI score and surgical outcomes\u003c/h3\u003e\n\u003cp\u003eThe distribution of operative time, complication rate according to the Clavien-Dindo classification, and hospital stay according to the pelvic compartment involved by endometriosis is summarized in the Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eMediocentral compartment was associated with a higher operative time (p\u0026thinsp;=\u0026thinsp;0.007), a longer hospital stays (p\u0026thinsp;=\u0026thinsp;0.04), but without increased incidence of grade III complication neither in the rate of voiding dysfunction.\u003c/p\u003e\u003cp\u003ePosterocentral compartment was associated with a higher operative time (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a longer hospital stays (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but without increased incidence of grade III complication neither in the rate of voiding dysfunction.\u003c/p\u003e\u003cp\u003eAnterocentral compartment was not associated with an increase in operative time, hospital stay, grade III complication, nor in voiding dysfunction.\u003c/p\u003e\u003cp\u003eMediolateral compartment was associated with a higher operative time (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a longer hospital stays (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a trend for a higher incidence of voiding dysfunction (p\u0026thinsp;=\u0026thinsp;0.05), but without increased incidence of grade III complication.\u003c/p\u003e\u003cp\u003ePosterolateral compartment was associated with a higher operative time (p\u0026thinsp;=\u0026thinsp;0.03), a longer hospital stays (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a higher incidence of voiding dysfunction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a trend for in increased incidence of grade III complication (p\u0026thinsp;=\u0026thinsp;0.1).\u003c/p\u003e\u003cp\u003eThe number of patients with involvement of the anterolateral compartment was too low to evaluate its impact on operative time, hospital stay, incidence of grade III complication nor on voiding dysfunction.\u003c/p\u003e\u003cp\u003eExtrapelvic endometriosis was associated with a higher operative time (p\u0026thinsp;=\u0026thinsp;0.02), a longer hospital stays (p\u0026thinsp;=\u0026thinsp;0.04), but without increased incidence of grade III complication neither in the rate of voiding dysfunction.\u003c/p\u003e\u003cp\u003eOperative time significantly increased with higher dPEI categories: 140 min (mild), 202 min (moderate), and 240 min (severe) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This trend showed a positive correlation (Spearman ρ\u0026thinsp;=\u0026thinsp;0.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Similarly, length hospital stay was associated with the dPEI category score, with an increase in median length of hospital stays: 3 days ,5 days and 6 days respectively for mild, moderate and severe endometriosis, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The difference was significant regardless of the groups of dPEI compared, with a positive correlation (Spearman\u0026rsquo;s ρ\u0026thinsp;=\u0026thinsp;0.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;2). The frequency of severe complications rose with the severity of the dPEI: 1.6% for mild, 7.8% for moderate, and 16.7% for severe cases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). Severe complications occurred more frequently in patients with severe endometriosis compared with patients with mild endometriosis (OR\u0026thinsp;=\u0026thinsp;13.1; 95% CI [1.54\u0026ndash;111.3]). De novo voiding dysfunction occurred in 4.7%, 7.8%, and 23.8% of mild, moderate, and severe dPEI categories, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). Voiding dysfunction occurred more frequently in patients with severe endometriosis compared with patients with mild endometriosis (OR\u0026thinsp;=\u0026thinsp;5.9; 95% CI [1.48\u0026ndash;23.5]).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective study confirms that the dPEI, initially validated for laparoscopic surgery, can also predict postoperative risk when applied to RAL for DPE.\u003c/p\u003e\u003cp\u003eIn the current study, RAL was primarily selected for patients presenting with severe disease according to the dPEI classification. In contrast to the multicenter external validation, where only 13.1% of patients had a dPEI\u0026thinsp;\u0026ge;\u0026thinsp;5, severe cases represented nearly one quarter of our series representing a potential bias to adequately evaluate the complication risk for this specific subpopulation. The prior validation study did not stratify outcomes by surgical approach, likely due to the predominant use of conventional laparoscopy. This limitation prevented extrapolation to RAL, although previous studies and meta-analyses have shown reduced hospital stay and postoperative complications, likely owing to better visualization and nerve identification with the robotic system, albeit at the cost of increased operative time [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our study, when considering the pelvic compartments, the mediocentral and the postrocentral compartments were the most frequently involved in 91.8% and 59.4%, respectively. Interestingly, the mediolateral compartment, defined by the involvement of parametrium, ureteral dilatation, and pelvic wall, and the posterolateral compartment, defined by the involvement of distal portion of uterosacral ligaments, sacrorectal septum, and pelvic wall were involved in 47.1% and 30% respectively. This also contrast with the multicenter external validation of the dPEI where the mediolateral compartment involvement was noted in only 21.6%. This difference is crucial as lateral compartments are well recognized to be associated with the risks of ureteral, vascular and nervous injuries with a higher risk of voiding dysfunction [\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, when comparing patients according to dPEI score categories, an increase in operative time, hospital stay, incidence of grade III complications according to the Clavien-Dindo classification was observed from mild to severe endometriosis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A positive correlation was found with longer operative time (Spearman\u0026rsquo;s ρ\u0026thinsp;=\u0026thinsp;0.40) and hospital stay (Spearman\u0026rsquo;s ρ\u0026thinsp;=\u0026thinsp;0.43). The increment in operative time, hospital stay, and complication rate observed in our series aligns with findings from the multicenter external validation of the dPEI [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These data support the relevance of the dPEI scoring system as a predictive tool of surgical outcomes after RAL for DPE thus contributing to improve decision making. To date, only a few tools can be used to tailor preoperative counseling for women with DPE. Poupon and al. proposed a nomogram for predicting complication risk in deep endometriosis without bowel involvement but its discriminative performance remained modest (AUC\u0026thinsp;=\u0026thinsp;0.72) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Bazot et al. introduced the Endostage MRI classification, which aims to correlate the anatomical spread of lesions with surgical difficulty, although it still awaits multicenter validation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOverall, 10.6% of patients developed de novo voiding dysfunction, rising to 23.8% among those with severe endometriosis\u0026mdash;mostly associated with medolateral and posterolateral compartments involvement. Moreover, when considering the duration of voiding dysfunction inferior or superior to one postoperative month for the whole population, the rates were 10.6% and 4.1%, respectively supporting that about two-thirds of the patients recovered normal micturition in the first postoperative month. In contrast, in the dPEI multicenter external validation, the occurrence of a voiding dysfunction was observed in only 7.4% of the whole population and was considered a grade II complication while this complication is not included in the Clavien-Dindo classification. The higher rate of urinary dysfunction observed here may relate to the substantial proportion of colorectal resections, a known risk factor for postoperative voiding disorders [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Transient (\u0026lt;\u0026thinsp;1 month) voiding dysfunction may be considered minor, whereas persistence beyond one month reflects a severe complication that substantially affects quality of life and may require neuromodulation therapy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40 CR41 CR42 CR43\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In addition, a previous meta-analysis on colorectal resection for endometriosis has emphasized that the rate of voiding dysfunction depended on the type of colorectal surgery. Indeed, rectal shaving was less associated with voiding dysfunction than segmental colorectal resection (OR : 0.34; CI : 0.18\u0026ndash;0.63, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) or discoid excision (OR : 0.22; CI : 0.09\u0026ndash;0.51, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) while no difference was found between discoid and segmental surgery [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our study, among the 150 patients with colorectal surgery (88% of the whole population), only 17.3% underwent a rectal shaving while the remaining patients underwent discoid excision or segmental resection. Moreover, previous studies have underlined the high rate of voiding dysfunction in case of vaginal and/or parametrial endometriosis that were required respectively in 22% and 41% of our patients [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Finally, in our study, when considering complications rates according to compartments involved, no differences between patients with a mediolateral and posterolateral compartment endometriosis were observed.\u003c/p\u003e\u003cp\u003eThis study has several limitations that warrant consideration. First, its retrospective design limits the ability to exclude residual biases. Second, no attempt was made to evaluate among patients with a severe dPEI whether the risk of complication varied according to the type of colorectal surgery (rectal shaving, discoid excision and segmental resection). Third, no attempt was done to evaluate the predictive value of 4th postoperative day CRP in the detection of complication after colorectal surgery for endometriosis [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. However, our rates of pelvic abscess and of rectovaginal fistulae (0.04% and 0.006%, respectively) were too low to allow a statistical evaluation. Lastly, the study did not include a cost-effectiveness analysis to determine whether the dPEI could serve as a practical selection tool for robotic surgery.\u003c/p\u003e\u003cp\u003eThe dPEI proved to be a reliable MRI-based index for predicting postoperative outcomes in patients undergoing RAL for DPE. Applying this index preoperatively may enhance patient counseling and multidisciplinary decision-making, particularly for individuals with extensive disease (dPEI\u0026thinsp;\u0026ge;\u0026thinsp;5). Future prospective studies are warranted to determine whether the robotic approach can effectively reduce the incidence of postoperative voiding dysfunction. Finally, in the absence of solid evidence demonstrating the cost-effectiveness of robotic surgery, the dPEI could help identify patients with severe forms of endometriosis who might derive the greatest benefit from a robotic approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAutor\u0026rsquo;s roles\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AR and SM. The statistics were performed by MF and CF. The first draft of the manuscript was written by AR and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The final draft was validated by ED et IT.\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConflict of interest:\u003c/h2\u003e\u003cp\u003eYohann Dabi, Meryl Dahan, Cl\u0026eacute;ment Ferrier, Cyril Touboul, Emile Dara\u0026iuml;, Shiwa Mansournia, Marie Florin and Isabelle Thomassin-Naggara have no conflict of interest to disclose.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AR and SM. The statistics were performed by MF and CF. The first draft of the manuscript was written by AR and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The final draft was validated by ED et IT.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed during the current study are not publicly available due to patient privacy and institutional data protection policies at Tenon Hospital (Paris, France). However, anonymized data supporting the findings of this study are available from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAs-Sanie S, Mackenzie SC, Morrison L, Schrepf A, Zondervan KT, Horne AW, Missmer SA, Endometriosis (2025) Rev JAMA 1 juill 334(1):64\u0026ndash;78\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGiudice LC, Endometriosis (2010) N Engl J Med 24 juin 362(25):2389\u0026ndash;2398\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor HS, Kotlyar AM, Flores VA (2021) Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. 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Eur J Obstet Gynecol Reprod Biol X juill 3:100028\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBazot M, Dara\u0026iuml; E, Benagiano GP, Reinhold C, Favier A, Roman H, Donnez J, Bendifallah S (2022) ENDO_STAGE Magnetic Resonance Imaging: Classification to Screen Endometriosis. J Clin Med. 26 avr. ;11(9):2443\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePartial colpectomy is a risk factor for urologic complications of colorectal resection for endometriosis - PubMed [Internet]. [cit\u0026eacute; 20 sept 2025]. 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Progres En Urol J Assoc Francaise Urol Soc Francaise Urol janv 28(1):2\u0026ndash;11\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eP\u0026eacute;cheux O, Dil\u0026eacute; P, Kerbage Y, Piessen G, Deken V, Collinet P, Rubod C (2021) Predictive value of 4th post-operative-day CRP in the early detection of complications after laparoscopic bowel resection for endometriosis. J Gynecol Obstet Hum Reprod 1 nov 50(9):102148\u003c/span\u003e\u003c/li\u003e\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":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Endometriosis, robotic-assisted laparoscopy, dPEI, surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7988692/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7988692/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe Deep Pelvic Endometriosis Index (dPEI) is a preoperative MRI-based score initially validated to predict surgical outcomes in patients undergoing laparoscopic treatment for deep pelvic endometriosis (DPE). Its applicability in robotic-assisted laparoscopy (RAL) has not yet been established.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study aimed to evaluate whether the dPEI can predict surgical outcomes following RAL for DPE.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed data prospectively collected from patients who underwent RAL for DPE at Tenon Hospital (Paris) between February 2019 and December 2024. Preoperative MRI staging was performed using the dPEI score, which stratifies DPE into mild (\u0026le;\u0026thinsp;2), moderate (3\u0026ndash;4), and severe (\u0026ge;\u0026thinsp;5). Surgical outcomes including operative time, hospital stay, postoperative complications using the Clavien\u0026ndash;Dindo classification and voiding dysfunction were assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA hundred and seventy patients were included. Overall complication rate was 24.7%, including 7.7% Clavien\u0026ndash;Dindo grade\u0026thinsp;\u0026gt;\u0026thinsp;II. De novo voiding dysfunction was observed in 10.6% of patients and persisted\u0026thinsp;\u0026gt;\u0026thinsp;1 month in 4.1%. dPEI categories showed a positive correlation with longer operative time (Spearman\u0026rsquo;s ρ\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and increased hospital stay (Spearman\u0026rsquo;s ρ\u0026thinsp;=\u0026thinsp;0.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and were also significantly associated with higher rates of grade\u0026thinsp;\u0026gt;\u0026thinsp;II complications (p\u0026thinsp;=\u0026thinsp;0.02) and high incidence of voiding dysfunction (p\u0026thinsp;=\u0026thinsp;0.01). Involvement of lateral compartments was associated with high operative time, hospital stay, and de novo voiding dysfunction.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOur results support the dPEI as a useful preoperative tool for predicting surgical outcomes after RAL for DPE. Its use can improve patient counseling, and shared decision-making, particularly in cases of severe disease (dPEI\u0026thinsp;\u0026ge;\u0026thinsp;5).\u003c/p\u003e","manuscriptTitle":"Validation of the Deep Pelvis Endometriosis Index (dPEI) to evaluate surgical outcomes of robotic-assisted surgery for endometriosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 07:50:24","doi":"10.21203/rs.3.rs-7988692/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T04:58:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T23:12:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48286257210238130853668554266622754453","date":"2025-11-02T22:17:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T11:30:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36504102086542422027788687621250881005","date":"2025-11-02T08:43:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117155721350732171435750779707594339264","date":"2025-10-31T01:41:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T18:06:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-30T18:03:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-30T12:41:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-10-30T11:07:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"72522d59-9185-42ce-a3ec-8145b27306dd","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:00:56+00:00","versionOfRecord":{"articleIdentity":"rs-7988692","link":"https://doi.org/10.1007/s11701-026-03141-x","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-01-19 15:57:20","publishedOnDateReadable":"January 19th, 2026"},"versionCreatedAt":"2025-11-13 07:50:24","video":"","vorDoi":"10.1007/s11701-026-03141-x","vorDoiUrl":"https://doi.org/10.1007/s11701-026-03141-x","workflowStages":[]},"version":"v1","identity":"rs-7988692","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7988692","identity":"rs-7988692","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}