Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis
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Authors:   Working group of ESGE, ESHRE, and WES, Keckstein Joerg , Becker Christian M , Canis Michel , Feki Anis , Grimbizis Grigoris F , Hummelshoj Lone , Nisolle Michelle , Roman Horace , Saridogan Ertan , Tanos Vasilios , Tomassetti Carla , Ulrich Uwe A , Vermeulen Nathalie , De Wilde Rudy Leon 
Published: February 2020

Abstract

STUDY QUESTION
How should surgery for endometriosis be performed?

SUMMARY ANSWER
This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT 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.

STUDY DESIGN, SIZE, DURATION
A 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, METHODS
This 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 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.

LIMITATIONS, REASONS FOR CAUTION
Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS
These 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 study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.

TRIAL REGISTRATION NUMBER
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