Surgical modalities for the treatment of recto-vaginal deep infiltrating endometriosis: systematic review and meta-analysis
Authors: Ibrahim Nesma Abdelhady Hassan , Salama Mohamed Hamed Abdelaziz , Nabhan Ashraf Fawzy 
Published: October 2021

Abstract

Background
Deeply infiltrating endometriosis is a distinct type of endometriosis that is characterized by presence of endometrial nodes that penetrates &gt;5 mm under the peritoneal surface. Surgery is the main method for relief of its associated pain and for improvement of quality of life.

Objectives
To assess effectiveness and safety of different laparoscopic surgical techniques in the treatment of deeply infiltrating endometriosis.

Search methods
We searched CENTRAL, MEDLINE, EMBASE, other data bases, and trial registries from inception till May 2020. The search strategy was developed by the review team. Some of the studies' authors were contacted for more clarification of information but we didn't get response.

Selection criteria
We included only randomized controlled trials (RCTs) that compare between the effectiveness and safety of different surgical techniques used in laparoscopic surgery to improve quality of life, treat pain, and improve sexual function in patients diagnosed with deeply infiltrating endometriosis

Data collection and analysis
Study selection, assessment of risk of bias of the included studies, and data collection were independently done by two of the review authors (Salama, M. and Ibrahim, N.). Any disagreement was resolved by discussion with the third review author (Nabhan, A.). We contacted investigators of some studies for more clarification of information and getting the primary data but we didn't get response. The quality of evidence was evaluated using GRADE methods.

Results
One RCT was included in the review. The study randomized 52 patients experiencing different types of pain and digestive symptoms, bad quality of life resulting from deeply infiltrating endometriosis. It compared laparoscopic versus open surgery in colorectal resection. The main limitations were unclear statement of allocation concealment, and lack of clearly described blinding beside the small number of participants. The study reported that there is no difference between the two approaches as regards to pain and symptomatic relief besides improving quality of life, but data are represented in median and range. The method of data presentation and absence of more studies in this comparison lead to the impossibility of doing meta-analysis. As for the other three comparisons we also found no studies that compared the surgical techniques together.

Authors' conclusions
There was insufficient evidence to conclude which surgical technique used during laparoscopy is the best regarding the relief of different types of pain associated with deeply infiltrating endometriosis and the improvement of quality of life of patients with such condition with the least adverse events. More research is needed in this field with very thorough consideration to the ethical dimensions of such trials in helping patients to get the best possible care according to their individual cases together with good design of the trial to enable the investigators to compare between different techniques.