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Recommendations for the surgical treatment of endometriosis.

Part 2: Deep endometriosis (DE)

This paper was produced by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) looking at the different types of surgery for deep endometriosis in women of reproductive age. Medical therapies may be used to treat endometriosis, but surgery is also often used to treat endometriomas. There are risks associated with surgery, and especially repeated surgery, including adhesions.

The working group presents technical recommendations for surgical treatment of deep endometriosis, from preoperative assessments to initial steps of surgery.

Pre-operative assessment of patients with suspected deep endometriosis should include:

· Medical history & symptoms assessment

- Recommended to use a validated symptom questionnaire to assess specific aspects of endometriosis, including pain symptoms, urinary function, bowel function, sexual function, recovery, depression, anxiety and fertility.

· Clinical examinations, including:

- Abdominal palpation

- Pelvic examination

- Vaginal examination

- Rectal examination

· Imaging

- Ultrasonography (TVUS or TVS, TRUS)

- Magnetic resonance Imaging (MRI)

- Computed Tomography (CT)

- Barium enema & sigmoidoscopy (stenosis of the bowel)

- Kidney sonography (mandatory for patients with deep endometriosis potentially involving the ureters)

Different surgical treatments may be required in respective of location and extent of disease. The paper is structured according to the different locations of deep endometriosis including:

· DE of the uterosacral ligaments and rectovaginal septum with or without involvement of the rectum

· Urinary tract endometriosis

· DE of the diaphragm

· DE of the abdominal wall including scars, the umbilicus, and the inguinal region

Recommendations on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis are also discussed.

The paper discusses technical details of the different types of surgery, potential risks, pre-operative planning and the involvement of different surgeons specializing in bowel or bladder is essential to ensure the best outcomes. The paper also provides recommendation for the classification of deep endometriosis that would help the surgeon in the planning and execution of surgery. Recommendations in this paper should be read in conjunction with the previous published guidelines on clinical management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma (Part 1).


Working group of ESGE, ESHRE, and WES, Keckstein, J., Becker, C. M., Canis, M., Feki, A., Grimbizis, G. F., Hummelshoj, L., Nisolle, M., Roman, H., Saridogan, E., Tanos, V., Tomassetti, C., Ulrich, U. A., Vermeulen, N., & De Wilde, R. L. (2020). Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Human reproduction open, 2020(1), hoaa002.


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