The article includes a clinical case of a patient with deep infiltrating endometriosis with rectum involving and using intraoperative controlled fluorescence in order to increase the radicality of surgery and improve the prognosis of the disease. Surgical excision of the endometrioitic nodules is the only effective way of treating patients with colorectal endometriosis in terms of relieving pain, improving quality of life and restoring reproductive function. The possible types of surgical interventions can be performed: endometrioid lesion shaving, discoid or circular intestinal resection with anastomosis. The extent of the operation is determined by the following morphological parameters: the number of endometrioid infiltrates of the intestinal wall, the size of each of them, the degree of involvement of the intestine circumference, the depth of the intestinal wall lesion, the distance from the level of anus to the endometriotic nodule and lymphatic dissemination.
В статье описан клинический случай лечения пациентки с глубоким эндометриозом с вовлечением прямой кишки с использованием интраоперационной управляемой флуоресценции с целью повышения радикальности оперативного вмешательства, улучшения прогноза течения заболевания. Хирургическое иссечение эндометриоидного инфильтрата — это единственный эффективный метод лечения пациенток с колоректальным эндометриозом в отношении купирования болевого синдрома, улучшения качества жизни и восстановления репродуктивной функции. Возможно выполнение следующих видов операций: шейвинг эндометриоидного очага, дисковидная или циркулярная резекция кишечника с наложением анастомоза. Объем операции определяется следующими морфологическими параметрами: числом эндометриоидных инфильтратов кишки, размером каждого из них, степенью вовлеченности окружности кишки, глубиной поражения кишечной стенки, расстоянием от уровня анального отверстия до очага, лимфатической диссеминацией.

OBJECTIVE: To organize the experience and international knowledge in the surgical management and staging of colorectal endometriosis, with a management proposal in stages.
METHODS: An extensive non-systematic review of the literature was carried to organize the disease in stages (limited, intermediate and advanced) according to a scoring system, which considers the characteristics of the endometrioma, the personal history and surgical findings. We tested the proposed staging in a retrospective group of patients.
RESULTS: From January 2017 to April 2023, we collected 19 patients with a confirmed diagnosis of colorectal endometriosis, treated laparoscopically, by the same group of surgeons, in whom we found a strong correlation between the stage of the disease and the presence of complications that required reinterventions.
CONCLUSIONS: We suggest a sequence of colorectal surgical management in stages according to the staging of the disease and we hope that this work will be followed by joint efforts to test it prospectively in order to compare results between hospital centers and make planned decisions.
OBJECTIVE: Organizar la experiencia y el conocimiento internacional en el manejo quirúrgico y la estadificación de la endometriosis colorrectal, con una propuesta de manejo por etapas.
UNASSIGNED: Se realizó una revisión amplia no sistemática de la literatura para organizar la enfermedad en etapas (limitada, intermedia y avanzada) de acuerdo con un sistema de puntuación que considera las características del endometrioma, los antecedentes personales y los hallazgos en la cirugía. La estatificación propuesta se probó en un grupo retrospectivo de pacientes.
RESULTS: De enero de 2017 a abril de 2023 recopilamos 19 pacientes con diagnóstico confirmado de endometriosis colorrectal, tratadas por vía laparoscópica, por el mismo grupo de cirujanos, en las que encontramos una fuerte correlación entre el estadio de la enfermedad y la presencia de complicaciones que requirieron reintervenciones.
CONCLUSIONS: Sugerimos una secuencia de manejo quirúrgico colorrectal en etapas de acuerdo con la estadificación de la enfermedad y esperamos que el presente trabajo sea seguido de esfuerzos compartidos por probarla de manera prospectiva para poder comparar resultados entre centros hospitalarios y tomar decisiones planificadas.

OBJECTIVE: Does colorectal endometriosis surgery prior to IVF ± intracytoplasmic sperm injection (ICSI) impact cumulative live birth rates?
METHODS: This retrospective, monocentric study (Lille University Hospital) was conducted between 1 January 2007 and 31 December 2018. Two groups of patients from the JFIV database were included: a group undergoing IVF±ICSI alone (120 patients, 215 oocyte retrievals), and a group undergoing surgery and then IVF±ICSI (69 patients, 109 oocyte retrievals). The mode of management was decided after a multidisciplinary team meeting. Different criteria such as age (cut-off 35 years), anti-Müllerian hormone concentration (cut off 2 ng/ml), imaging results and the patient\'s symptomatology were considered: the most symptomatic patients underwent surgery prior to IVF±ICSI. The cumulative clinical pregnancy and live birth rates obtained after four IVF attempts were estimated and compared between the two groups using competing risk survival methods.
RESULTS: The cumulative live birth rates after four IVF attempts in the two groups were not statistically significantly different (50.8% in the IVF±ICSI group versus 52.2% in the surgery followed by IVF±ICSI group, P = 0.43). The results for the cumulative clinical pregnancy rates were the same (56.7% in the IVF±ICSI group versus 58% in the surgery followed by IVF±ICSI group, P = 0.47).
CONCLUSIONS: The study shows that cumulative live birth and pregnancy rates were similar in infertile patients with colorectal endometriosis who underwent IVF±ICSI either with or without prior colorectal endometriosis surgery.

OBJECTIVE: The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes.
METHODS: 49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed.
RESULTS: Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients\' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16).
CONCLUSIONS: Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.

Colorectal endometriosis (CEM) is a rare and complicated form of deep invasive endometriosis. Its treatment methods include drug therapy and surgery. However, it is often difficult to alleviate symptoms and address problems, such as infertility, using drug treatment alone. Surgical intervention provides a histologic diagnosis, allows assessment of pelvic cysts or masses with features concerning for malignancy, and reduces pain by destroying the endometriotic implants. We consider surgery in women with the following: Persistent pain despite medical therapy; Contraindications to or refusal of medical therapy; Need for a tissue diagnosis of endometriosis; Exclusion of malignancy in an adnexal mass; Obstruction of the bowel or urinary tract. But there is no consensus about the surgical methods. With the rapid development of gastroenteroscopy technology in recent years, many local gastrointestinal tumors that previously required surgical resection can now be removed by endoscopic surgery. Herein, we report one case of CEM treated by endoscopic submucosal excavation (ESE) to provide a new treatment option for the radical resection of single CEM.

To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm.
Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data.
A tertiary referral center.
Patients undergoing excision of rectal endometriosis.
Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach.
Feasibility of the technique.
The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler\'s jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required.
The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.

Endometriosis is a disease affecting approximately 10% of women of fertile age. A particular presentation is deep infiltrating endometriosis of the rectosigmoid colon with symptoms that can mimic an intestinal obstruction or neoplasm. We report the case of a 39-year-old woman with pelvic pain during the menstrual cycle and significant anemia who presented an ectopic endometrial tissue in correspondence of the rectum. Because of the thickness of the lesion the patient underwent a segmental laparoscopic colorectal resection with end-to-end anastomosis.

BACKGROUND: Patients suffering from colorectal deep endometriosis (DE) experience gastrointestinal symptoms with almost the same frequency as gynecological pain symptoms. Preoperatively existing gastrointestinal symptoms may translate into pathological gastrointestinal quality of life index (GIQLI) and low anterior resection syndrome scores (LARS). This prospective questionnaire-based case control study aims to assess the prevalence of gastrointestinal complaints reflected by changes in LARS and GIQLI scores in patients with colorectal deep endometriosis prior to surgical treatment and compare those to a healthy control group.
METHODS: The study was conducted at the Hospital St. John of God in Vienna and included a total of 97 patients with histologically confirmed colorectal DE with radical surgical treatment and 96 women in whom DE was excluded via transvaginal sonography (TVS) or visually. Gastrointestinal symptoms reflected by LARS and GIQLI scores were evaluated presurgically and in controls.
RESULTS: A total of 193 premenopausal patients were included in this study. A mean GIQLI of 90.7 ± 22.0 and 129.4 ± 11.1 was observed among patients and controls, respectively, showing a significantly higher morbidity concerning gastrointestinal symptoms and decreased quality of life (QoL) compared to healthy controls (p < 0.001). The LARS score results demonstrated that 18.6% of the patients with bowel DE presented with a major LARS and 27.8% with a minor LARS presurgically compared to 2.1% and 9.4% of control patients, respectively (p < 0.001).
CONCLUSIONS: Patients with colorectal DE experience a quality of gastrointestinal symptoms translating into a decreased QoL and pathological GIQLI and LARS scores already presurgically. As a consequence, these instruments should be interpreted with caution.

Surgical experience and hospital procedure volumes have been associated with the risk of severe complications in expert centers for endometriosis in France. However, little is known about other certified units in Central European countries.
This retrospective observational study included 937 women who underwent surgery for colorectal endometriosis between January 2018 and January 2020 in 19 participating expert centers for endometriosis. All women underwent complete excision of colorectal endometriosis by rectal shaving, discoid or segmental resection. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification system including anastomotic leakage, fistula, pelvic abscess and hematoma. Surgical outcomes of centers performing less than 40 (group 1), 40-59 (group 2) and ≥60 procedures (group 3) over a period of 2 years were compared.
The overall complication rate of grade III and IV complications was 5.1% (48/937), with rates of anastomotic leakage, fistula formation, abscess and hemorrhage in segmental resection, discoid resection and rectal shaving, respectively, as follows: anastomotic leakage 3.6% (14/387), 1.4% (3/222), 0.6% (2/328); fistula formation 1.6% (6/387), 0.5% (1/222), 0.9%; (3/328); abscess 0.5% (2/387), 0% (0/222) and 0.6% (2/328); hemorrhage 2.1% (8/387), 0.9% (2/222) and 1.5% (5/328). Higher overall complication rates were observed for segmental resection (30/387, 7.8%) than for discoid (6/222, 2.7%, P = 0.015) or shaving procedures (12/328, 3.7%, P = 0.089). No significant correlation was observed between the number of procedures performed and overall complication rates (rSpearman  = -0.115; P = 0.639) with a high variability of complications in low-volume centers (group 1). However, an intergroup comparison revealed a significantly lower overall severe complication rate in group 3 than in group 2 (2.9% vs 6.9%; P = 0.017) without significant differences between other groups.
A high variability in complication rates does exist in centers with a low volume of activity. Major complications may decrease with an increase in the volume of activity but this effect cannot be generally applied to all institutions and settings.

BACKGROUND: Deep infiltrative endometriosis can lead to infertility with a spontaneous pregnancy rate between 8.7 and 13%. Surgical treatment of bowel endometriosis may improve spontaneous and ART fertility. The aim of this study was to evaluate post-operative fertility according to the surgical technic used (shaving vs. bowel resection).
METHODS: A retrospective, monocentric study was carried-out in the University Hospital of Strasbourg, France, from September 2009 to October 2016. All patients with a desire to become pregnant and treated for colorectal deep infiltrating endometriosis were included. Two groups were analyzed and compared: shaving treatment vs. digestive resection (discoid or segmental). The primary outcome was pregnancy rate after surgery. Secondary outcomes were: mode of pregnancy occurrence (spontaneous versus ART), time of onset, term at birth, occurrence of complications during pregnancy.
RESULTS: 94 patients were included (39 had a bowel resection and 55 a shaving). Both groups had similar pre-operative characteristics. The pregnancy rate was 52,1% for the total population with no significant differences between the two groups (p = 0.68). However, we found a significantly higher spontaneous pregnancies rate among the resection group with 73.7% (p = 0,0086). Pregnancy complications occurred in 50% of pregnancies, regardless of the surgical technic used.
CONCLUSIONS: This study suggests that, for patients with colorectal DIE, surgical treatment improves overall fertility. Furthermore, resection surgery seems to significantly improve the occurrence of spontaneous pregnancies. However, this surgery is not without risks and multidisciplinary discussions and thorough information to the patient are a prerequisite.