Highlight
This 10-year longitudinal analysis of the ENDORE randomized trial provides rare, robust evidence comparing conservative nodule excision and segmental colorectal resection in managing rectal deep endometriosis. Both surgical approaches demonstrate similar durable improvements in bowel function, quality of life, and low recurrence and reoperation rates, with high natural pregnancy rates among women desiring conception.
Study Background
Deep infiltrating endometriosis involving the rectum poses substantial clinical challenges due to its complex manifestations, including severe pelvic pain, bowel dysfunction, and infertility. Surgical intervention remains a cornerstone of treatment, but the optimal approach—conservative nodule excision (shaving or disc excision) versus more radical segmental resection—has been debated, with prior studies limited by observational designs, selection bias, and short-term follow-up. Long-term outcomes are particularly critical to inform surgical decision-making, given the potential for persistent symptoms, functional complications, and risk of disease recurrence that can severely impair quality of life.
Study Design
The study is a 10-year follow-up of the ENDORE single-center randomized controlled trial conducted at Rouen University Hospital from May 2011 to October 2013. It enrolled 55 women diagnosed with deep endometriosis infiltrating the rectum within 15 cm of the anus, involving at least 20 mm diameter of muscular involvement but affecting no more than 50% of the rectal circumference.
Participants were randomized to undergo either conservative surgical management (nodule excision—shaving or disc excision) or segmental colorectal resection. The primary endpoint was the proportion of patients experiencing at least one symptom indicative of bowel or bladder dysfunction, including constipation (defined as one stool in over five consecutive days), defecation pain, frequent bowel movement (≥3 stools/day), anal incontinence, or bladder dysfunction indicated by Urinary Symptom Profile.
Secondary endpoints included validated patient-reported outcome measures: Knowles-Eccersley-Scott-Symptom Questionnaire (KESS) for bowel function, Gastrointestinal Quality of Life Index (GIQLI), Wexner scale for incontinence, Urinary Symptom Profile (USP), SF-36 health survey, as well as pregnancy rates, recurrence of rectal endometriosis, and reoperation rates.
Key Findings
Of the initial 55 participants, 50 (91%) completed the 10-year follow-up. Statistical analysis demonstrated no significant difference between the two surgical cohorts in the primary outcome: symptomatic dysfunction was reported in 74.1% (nodule excision) versus 71.4% (segmental resection) (OR 0.88, 95% CI 0.27-2.9, P=0.83). Similarly, subjective patient reports of normal bowel movements were comparable (59.1% vs 58.3%, OR 0.97, 95%CI 0.30-3.1, P=0.96).
Longitudinal analysis using Generalized Estimating Equations confirmed parallel trajectories over 10 years for bowel and urinary function and quality of life scores, indicating sustained benefits post-surgery irrespective of technique. No significant differences emerged in secondary outcome measures including KESS, GIQLI, Wexner, USP, and SF-36 scores.
Recurrence rates of rectal endometriosis were low in both groups: 7.4% in the excision arm versus 3.6% in the resection arm (OR 0.46, 95% CI 0.04-5.4, P=0.54). Despite these recurrences, reoperation rates remained similar between groups at 32.7% overall. Fertility outcomes were encouraging, with an 85.3% pregnancy rate among women attempting conception postoperatively; two thirds conceived naturally and 45 infants were delivered overall.
Expert Commentary
This landmark study is among the first randomized trials providing robust long-term comparative data on rectal endometriosis surgery. Importantly, the equivalence in outcomes between conservative and radical approaches challenges the preconception that segmental resection necessarily confers superior symptom control or disease clearance. The findings uphold conservative surgery as a valid strategy for preserving bowel integrity without compromising long-term symptom relief or increasing recurrence risks.
However, interpretation should consider the study’s single-center design and relatively small cohort size despite rigorous follow-up. The inclusion criteria restricted to moderate-to-large but not circumferential nodules may limit generalizability to more extensive disease. Additionally, surgical expertise and patient selection are crucial determinants of outcomes, underscoring the need for tailored multidisciplinary management.
Overall, these data align with growing literature advocating a patient-centered, minimally invasive surgical paradigm prioritizing functional preservation and quality of life in deep endometriosis management.
Conclusion
In women with sizable rectal endometriosis involvement, both conservative nodule excision and segmental colorectal resection provide durable 10-year functional and symptomatic benefits. No significant differences in long-term bowel or urinary dysfunction, recurrence, or reoperation rates were observed. Fertility outcomes post-surgery were notably favorable.
This evidence supports individualized surgical counseling balancing disease extent, symptom severity, fertility desires, and surgical risks. Further multicenter studies with larger cohorts will enhance confidence in these findings and refine guidelines to optimize outcomes for women suffering from this debilitating condition.
Funding and Clinical Trials Registration
The study was conducted at Rouen University Hospital with no direct funding source specified in the abstract. The ENDORE trial is registered with clinicaltrials.gov under the identifier NCT number not provided in the abstract.
References
1. Roman H et al. Long term outcomes of surgical management of rectal endometriosis: 10-year follow-up of patients enrolled in a randomized trial. Am J Obstet Gynecol. 2026 Jul 14. PMID: 42447975.
2. Meuleman C et al. Surgical treatment of deep infiltrating endometriosis with bowel involvement: long-term results. Hum Reprod. 2015;30(2):329-344.
3. Roman H et al. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod. 2020;35(1):139-148.
4. Ballester M et al. Fertility outcomes after surgery for deep infiltrating endometriosis: A systematic review. Human Reproduction Update. 2019;25(5):568-585.
