Is colorectal resection necessary to improve pain and fertility outcomes in patients with deep endometriosis?

Bowel endometriosis is often considered an indication for extensive surgical management, including colorectal resection, in women undergoing surgery for concomitant endometriosis at other sites. However, several contemporary studies show little or no correlation between the anatomical extent of bowel endometriosis and symptom severity, and current data do not support a direct relationship between bowel disease extent and fertility impairment. Furthermore, the evidence supporting an additional benefit of colorectal resection with respect to pain relief and fertility outcomes remains limited in patients undergoing surgery for deep endometriosis and/or peritoneal and ovarian endometriosis. Notably, when applying strict methodological criteria, only a single comparative cohort evaluated outcomes in women with colorectal endometriosis undergoing surgery with versus without colorectal resection. This cohort did not demonstrate superior pain or fertility outcomes associated with bowel resection. Considering the well-known potential of severe complications of colorectal surgery, these findings challenge the assumption that anatomical completeness equates to clinical benefit. Given the sparse evidence demonstrating a clear proven clinical benefit of adding bowel surgery to surgical removal of endometriosis at other sites, a critical re-evaluation of surgical proportionality is warranted. Robust comparative studies are urgently needed to justify systematic colorectal resection in bowel endometriosis.