There are very few methodologically valid studies evaluating clinical outcome after deeply infiltrative with colorectal extension, as demonstrated in a systematic review (313). In a review on the clinical outcome of surgical treatment of deeply infiltrating endometriosis with colorectal involvement, most of the 49 reviewed studies included complications (94%) and pain (67%); few studies reported recurrence (41%), fertility (37%), and quality of life (10%); only 29% reported (loss of) follow-up. Of 3,894 patients, 71% underwent bowel resection and anastomosis, 10% had full-thickness excision, and 17% were treated with superficial surgery. Comparison of clinical outcome between different surgical techniques was not possible. Postoperative complications were present in 0% to 3% of the patients. Although pain improvement was reported in most studies, pain evaluation was patient based in less than 50% (visual analog scale [VAS] in only 18%). Although quality of life was improved in most studies, prospective data were available for only 149 patients. Pregnancy rates were 23% to 57% with a cumulative pregnancy rate of 58% to 70% within 4 years. The overall endometriosis recurrence rate in studies (longer than 2 years follow-up) was 5% to 25%, with most of the studies reporting 10%. Owing to highly variable study design and data collection, a Consolidated Standards of Reporting Trials (CONSORT)-inspired checklist was developed for future studies (313). Prospective studies reporting standardized and well-defined clinical outcome after surgical treatment of deeply invasive endometriosis with colorectal involvement with long-term follow-up are needed (313).
The outcome of surgical therapy in patients with endometriosis and pain is inﬂuenced by many psychological factors relating to personality, depression, and marital and sexual problems. It is difficult to evaluate scientifically the objective effect of different surgical approaches because the extirpation and destruction of the pathological tissue can impact the results as can surgery per se, the doctor–patient relationship, complications, and other factors. There is a significant placebo response to surgical therapy: diagnostic laparoscopy without complete removal of endometriosis may alleviate pain in 50% of patients (295,314,315). Similar results were reported using oral placebos (316). Although some reports claimed pain relief with laser laparoscopy in 60% to 80% of patients with very low morbidity, none was prospective or controlled or allowed a definitive conclusion regarding treatment efficacy (200,317–320). The longstanding effect of surgery on pain is difficult to evaluate because the follow-up time is too short, usually just a few months. The major shortcoming of surgical treatment in endometriosis related pain is the lack of prospective randomized studies with sufficient follow-up time to draw clear clinical conclusions.