Juan Carlos Ramirez Mejía¹, Karen Daniela Paola Cepeda Forero²*, Roberto Guillén Moreno³, Linda Lucía Cardoso Franco⁴ and Anwar Medellin Anbueta⁵

¹Advanced Laparoscopist, Gynecology, Obstetrics and Human Reproduction, Fundación Santa Fe de Bogotá, Colombia
²Gynecology, Obstetrics and Human Reproduction, Fundación Santa Fe de Bogotá, Colombia
³Medical Residency in Gynecology and Obstetrics, Universidad de Panamá, Ciudad de Colón, Panamá
⁴Clinical Care Center for Endometriosis, Fundación Santa Fe de Bogotá, Colombia
⁵Chief of the Colon and Rectal Surgery Section, Fundación Santa Fe de Bogotá, Colombia

*Corresponding Author: Karen Daniela Paola Cepeda Forero, Gynecology, Obstetrics and Human Reproduction, Fundación Santa Fe de Bogotá, Colombia.

Received: July 09, 2025; Published: July 30, 2025

Abstract

Colorectal endometriosis is a subtype of deep infiltrating endometriosis that affects up to 23% of patients with pelvic endometriosis, commonly involving the rectosigmoid junction. This condition presents significant diagnostic and therapeutic challenges due to its nonspecific gastrointestinal symptoms and frequent overlap with other conditions like irritable bowel syndrome. Although medical treatment may relieve certain symptoms, it remains ineffective in addressing fibrosis and deeply infiltrative lesions, often making surgical management necessary. Current surgical options include rectal shaving, discoid excision, and segmental bowel resection. However, there is no consensus on standardized indications for each technique, and recommendations from expert societies remain limited.

This narrative review critically evaluates existing literature regarding surgical outcomes, postoperative complications, recurrence rates, and quality of life improvements associated with the three main surgical approaches. Rectal shaving, the most conservative technique, demonstrates lower operative time and fewer complications such as rectovaginal fistula and anastomotic leakage. Discoid excision is favored for unifocal lesions affecting a moderate portion of the bowel wall and also shows acceptable complication rates. Segmental resection, although the most radical, is generally reserved for multifocal or larger lesions and is associated with higher morbidity but lower recurrence.

Meta-analyses indicate that conservative techniques are associated with better bowel function, lower rates of voiding dysfunction, and improved quality of life scores compared to radical resection. However, recurrence is more common with shaving compared to segmental resection, particularly in lesions with greater depth or luminal involvement. Preoperative imaging modalities such as MRI and endoscopic ultrasound can improve lesion characterization and help predict the need for more extensive surgery. Despite a growing body of evidence, the overall quality of existing studies remains low, often limited to retrospective observational designs with variable follow-up periods. This underscores the urgent need for prospective, standardized studies that account for lesion size, location, and patient-centered outcomes.

This review proposes a pragmatic algorithm for the surgical management of colorectal endometriosis, integrating imaging findings, lesion characteristics, and patient preferences. The ultimate goal is to personalize surgical strategies to achieve complete excision of disease, reduce symptom burden, minimize complications, and lower recurrence risk—thereby improving both clinical and quality-of-life outcomes in affected women.

Keywords: Endometriosis; Minimally Invasive Surgical Procedures; Colorectal Surgery

References

1. Donnez  “Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases”. Journal of Clinical Medicine  10.21 (2021): article 5183.
2. Harder , et al. “Assessing the True Prevalence of Endometriosis: A Narrative Review of Literature Data”. International Journal of Gynecology and Obstetrics  167. 3 (2024):  883-900.
3. Quintairos Ricardo de , et al. “Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta analysis of Bowel Function”. Journal of Minimally Invasive Gynecology  29.11 (2022):  1231-1240.
4. O’Brien , et al. “Conservative Surgery versus Colorectal Resection for Endometriosis with Rectal Involvement: A Systematic Review and Meta analysis of Surgical and Long Term Outcomes”. International Journal of Colorectal Disease  38.1 (2023): article 55.
5. Lukac , et al. “Extragenital Endometriosis in the Differential Diagnosis of Non Gynecological Diseases”. Deutsches Ärzteblatt International  119.20 (2022):  361-367.
6. Balla , et al. “Outcomes after Rectosigmoid Resection for Endometriosis: A Systematic Literature Review”. International Journal of Colorectal Disease  33.7 (2018):  835-847.
7. Cepeda Silva , et al. “Colorectal Endometriosis: A Proposal for Complementary Classification and Surgical Management by Stages”. Cirugía y Cirujanos  92.1 (2024): e11852.
8. Donnez Olivier and Jacques  “Deep Endometriosis: The Place of Laparoscopic Shaving”. Best Practice and Research Clinical Obstetrics and Gynaecology  71 (2021):  100-113.
9. Arcoverde Fernanda V , et al. “Surgery for Endometriosis Improves Major Domains of Quality of Life: A Systematic Review and Meta analysis”. Journal of Minimally Invasive Gynecology  26. 2 (2019):  266-278.
10. Riiskjær , et al. “Pelvic Pain and Quality of Life before and after Laparoscopic Bowel Resection for Rectosigmoid Endometriosis: A Prospective, Observational Study”. Diseases of the Colon and Rectum  61.2 (2018):  221-229.
11. Becker Christian ., et al. “ESHRE Guideline: Endometriosis”. Human Reproduction Open 2 (2022): article hoac009.
12. Chou , et al. “Shaving for Bowel Endometriosis”. Journal of Minimally Invasive Gynecology  27.2 (2020):  268-269.
13. Nisolle Michelle., et al. “Choosing the Right Technique for Deep Endometriosis”. Best Practice and Research Clinical Obstetrics and Gynaecology  59 (2019):  56-65.
14. Donnez Olivier and Horace  “Choosing the Right Surgical Technique for Deep Endometriosis: Shaving, Disc Excision, or Bowel Resection?” Fertility and Sterility  108.6 (2017):  931 942.
15. Bendifallah , et al. “Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta analysis”. Journal of Minimally Invasive Gynecology  28.3 (2021):  453 466.
16. Hudelist , et al. “Rates of Severe Complications in Patients Undergoing Colorectal Surgery for Deep Endometriosis—a Retrospective Multicenter Observational Study”. Acta Obstetricia et Gynecologica Scandinavica 101.10 (2022):  1057-1064.
17. Bendifallah , et al. “Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta analysis”. Journal of Minimally Invasive Gynecology  27.2 (2020):  441-451.e2.
18. Ianieri Manuel , et al. “Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature”. Journal of Minimally Invasive Gynecology  25. 5 (2018):  786-793.
19. Roman , et al. “Excision versus Colorectal Resection in Deep Endometriosis Infiltrating the Rectum: Five Year Follow up of Patients Enrolled in a Randomized Controlled Trial”. Human Reproduction  34.12 (2019):  2362 2371.
20. Roman , et al. “Bowel Dysfunction before and after Surgery for Endometriosis”. American Journal of Obstetrics and Gynecology  209. 6 (2013):  524-530.
21. Popoutchi , et al. “Surgical Techniques for the Treatment of Rectal Endometriosis: A Systematic Review of Randomized Controlled Trials and Observational Studies”. Arquivos de Gastroenterologia  58.4 (2021):  548-559.
22. Abo , et al. “Discoid Resection for Colorectal Endometriosis: Results from a Prospective Cohort from Two French Tertiary Referral Centres”. Colorectal Disease  21.11 (2019):  1312-1320.
23. Abo , et al. “Postoperative Complications after Bowel Endometriosis Surgery by Shaving, Disc Excision, or Segmental Resection: A Three Arm Comparative Analysis of 364 Consecutive Cases”. Fertility and Sterility  109.1 (2018):  172-178.e1.
24. Braund , et al. “Risk of Postoperative Stenosis after Segmental Resection versus Disk Excision for Deep Endometriosis Infiltrating the Rectosigmoid: A Retrospective Study”. Journal of Minimally Invasive Gynecology  28.1 (2021):  50 56.
25. Madar, , et al. “Voiding Dysfunction after Surgery for Colorectal Deep Infiltrating Endometriosis: An Updated Systematic Review and Meta analysis”. Updates in Surgery (2025).
26. Desplats , et al. “Preoperative Rectosigmoid Endoscopic Ultrasonography Predicts the Need for Bowel Resection in Endometriosis”. World Journal of Gastroenterology  25.6 (2019):  696-706.
27. Scardapane , et al. “Magnetic Resonance Colonography May Predict the Need for Bowel Resection in Colorectal Endometriosis”. BioMed Research International (2017): 2606123.

Citation

Citation: Karen Daniela Paola Cepeda Forero., et al