Surgical, Clinical, and Functional Outcomes in Patients with Rectosigmoid Endometriosis in the Gray Zone: 13-Year Long-Term Follow-up

Study Objective: To compare long-term surgical, clinical, and functional outcomes between conservative and radical surgery in patients with rectosigmoid endometriosis (RSE) and preoperative intermediate risk of segmental resection. Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: Endometriosis tertiary level referral center, St. Orsola Academic Hospital, Bologna, Italy. Patients: Three hundred and ninety-two patients with RSE presented for complete macroscopic surgical excision between January 2004 and January 2017. Intervention: Assessment of laparoscopic bowel shaving, discoid excision, or segmental resection for the treatment of RSE. Measurements and Main Results: The 392 patients were divided into 3 groups according to surgical technique: shaving (n = 297; 75.8%), discoid excision (n = 33; 8.4%), and segmental resection (n = 62; 15.8%). Preoperative characteristics, surgical data, short- and long-term complications, and rates of proven and suspected recurrence were assessed. The segmental resection group had a higher rate of short-term complications compared with the discoid and shaving groups (17.7% vs 9.1% vs 5.4%, respectively; p = .004). The median follow-up time was 43 months (range, 12–163 months). Suspected and proven RSE recurrence rates showed no statistically significant differences among the 3 groups. There also were no significant differences concerning the rate of de novo chronic constipation and urinary retention. Conclusion: To date, there is no consensus regarding the choice between radical (segmental resection) or conservative (shaving, discoid excision) surgical management for RSE, particularly for patients with preoperative intermediate risk of bowel segmental resection (the gray zone). Our data suggest that conservative surgery is preferred over radical surgery in patients with RSE in the gray zone risk category, resulting in similar suspected and proven RSE recurrence rates and associated with fewer short-term complications.