Introduction
Deep infiltrating endometriosis affecting the bowel presents a complex clinical challenge. Consequently, long-term evidence for rectal endometriosis surgery remains highly critical for guiding clinical decisions. Historically, clinicians relied heavily on cohort studies with high attrition rates. To address this gap, researchers analyzed a ten-year follow-up of the landmark ENDORE randomized controlled trial. This analysis provides robust clarity on rectal endometriosis surgery for clinicians worldwide.
Study Design and Methodology
Specifically, the trial enrolled fifty-five patients at Rouen University Hospital between May 2011 and October 2013. All participants suffered from deep endometriosis infiltrating the rectum within 15 cm from the anus. Furthermore, these patients had large rectal nodules over the muscular layer. These nodules exceeded 20 mm in diameter and involved up to half of the rectal circumference. Investigators randomly assigned patients to receive either conservative nodule excision or radical segmental colorectal resection. Ultimately, ninety-one percent of the patients completed the comprehensive ten-year follow-up, ensuring exceptional data reliability.
Key Functional Outcomes
The primary endpoint focused on bowel and bladder symptoms, including constipation, defecation pain, frequent defecation, anal incontinence, and bladder dysfunction. Surprisingly, this primary endpoint occurred in 74.1% of excision patients and 71.4% of resection patients. Therefore, statistical analysis showed no significant difference between the two surgical groups. Additionally, approximately 59% of patients in both groups subjectively reported normal bowel movements.
Long-Term Outcomes of Rectal Endometriosis Surgery
To evaluate the clinical trajectory, investigators compared multiple validated questionnaires over ten years. Specifically, they utilized the Knowles-Eccersley-Scott-Symptom Questionnaire (KESS) and the Gastrointestinal Quality of Life Index (GIQLI). They also tracked the Wexner scale, the Urinary Symptom Profile (USP), and the SF36 quality-of-life scores. Consequently, the longitudinal Generalized Estimating Equations analysis revealed no differences between the two surgical arms over time. Thus, the surgery-related benefits of rectal endometriosis surgery persisted stably throughout the entire decade.
Pregnancy and Recurrence Rates
Importantly, patients seeking pregnancy achieved excellent fertility outcomes after their procedures. Specifically, the overall pregnancy rate reached 85.3% among women with pregnancy intention. Furthermore, most of these patients conceived naturally (64.4%), resulting in 45 children born to 27 women.
Regarding safety, the ten-year rectal endometriosis recurrence rates were 7.4% in the excision group and 3.6% in the resection group. Although the excision rate was slightly higher, this difference lacked statistical significance. Meanwhile, about 32.7% of patients required a second surgery related to endometriosis, with no differences between the groups. Consequently, both techniques demonstrate equivalent durability, safety, and excellent long-term fertility profiles.
Frequently Asked Questions
Q1: Is there a significant difference in long-term functional outcomes between conservative excision and radical resection for rectal endometriosis?
No, the 10-year follow-up results from the ENDORE trial demonstrate no statistically significant difference in long-term digestive and urinary functional outcomes between the two surgical approaches.
Q2: What are the recurrence and reoperation rates after rectal endometriosis surgery over a ten-year period?
The 10-year rectal recurrence rates were 7.4% for conservative excision and 3.6% for segmental resection, which was not a statistically significant difference. Meanwhile, approximately 32.7% of patients across both groups required a second surgery related to endometriosis.
Q3: How does rectal endometriosis surgery affect future fertility and pregnancy rates?
The study reveals highly encouraging fertility outcomes, with an overall pregnancy rate of 85.3% among patients attempting to conceive. Importantly, a majority of these patients (64.4%) conceived naturally.
References
- Roman H et al. Long term outcomes of surgical management of rectal endometriosis: 10-year follow-up of patients enrolled in a randomized trial. Am J Obstet Gynecol. 2026 Jul 14. doi: undefined. PMID: 42447975.
- Roman H et al. Excision versus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial. Hum Reprod. 2019 Dec;34(12):2362-2371. doi: 10.1093/humrep/dez221. PMID: 31821473.
- Roman H et al. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod. 2018 Jan 1;33(1):47-57. doi: 10.1093/humrep/dex336. PMID: 29165604.