Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis

STUDY QUESTIONHow should surgery for endometriosis be performed?SUMMARY ANSWERThis document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.WHAT IS KNOWN ALREADYEndometriosis 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.STUDY DESIGN, SIZE, DURATIONA working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.PARTICIPANTS/MATERIALS, SETTING, METHODSThis document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.MAIN RESULTS AND THE ROLE OF CHANCEThe 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.LIMITATIONS, REASONS FOR CAUTIONOwing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.WIDER IMPLICATIONS OF THE FINDINGSThese recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.STUDY FUNDING/COMPETING INTEREST(S)The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the