Recommendations for the surgical treatment of endometriosis. \nPart 2: deep endometriosis

Study question: How should surgery for endometriosis be performed? \n/ \nSummary answer: This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age. \n/ \nWhat is known already: Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe. \n/ \nStudy, design, size, duration: A working group of the European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis. \n/ \nParticipants, materials, setting, methods: This document focused on surgery for deep endometriosis, and is complementary to a previous document in this series focusing on endometrioma surgery. \n/ \nMain results and the role of chance: The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis. \n/ \nLimitations, reasons for caution: Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added. \n/ \nWider implications of the findings: These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma. \n/ \nStudy funding - Competing interest(s): The meetings of the working group were funded by ESGE, ESHRE and WES.