Disease Extent Linked to Complications After Deep Endometriosis Surgery

Each additional involved compartment of deep endometriosis was associated with 51% higher odds of clinically relevant complications after one-stage laparoscopic resection, according to a multicenter cohort study published in BJOG: An International Journal of Obstetrics & Gynaecology.¹

One-stage surgery treats deep endometriosis in both anterior and posterior pelvic compartments in a single procedure. Evidence on outcomes after multicompartment surgery is limited because most studies focus on single compartments or small cohorts.

The investigators analyzed 299 consecutive patients with pathologically confirmed deep endometriosis treated at tertiary centers in Bern, Switzerland, and Budapest, Hungary, from 2017 to 2025. Median age was 34 years, 96% had revised American Society for Reproductive Medicine stage III or IV disease, and 45.8% had prior endometriosis surgery.

Complication Rates After One-Stage Surgery

Overall, 12.0% of patients (n = 36) had postoperative complications. On the Clavien-Dindo surgical complication scale, grade II or higher occurred in 11.7% and grade IIIb or higher in 4.7%.

The most common complications were bladder dysfunction (3%), paralytic ileus (2%), and urinary tract infection (2%). Anastomotic leakage requiring reoperation occurred in 1.7% of patients, enterogenital fistula in 1.0%, and pelvic abscess in 0.7%.

In the primary model, limited to 3 covariates because only 35 patients had clinically relevant complications, each additional involved compartment under the #ENZIAN system, which maps the location and extent of deep disease, carried an adjusted odds ratio (aOR) of 1.51 (95% CI, 1.04-2.18; P = .030). The authors wrote that extent "may better reflect surgical complexity than involvement of a single anatomical site" and called the association a marker of complexity, not a causal effect.

Preoperative dienogest use was associated with higher odds of complications in an exploratory model (aOR, 2.52; 95% CI, 1.18-5.35), but the extent was no longer significant there (aOR, 1.42; 95% CI, 0.97-2.08). The investigators cautioned against inferring harm, citing nonrandomized allocation and plausible confounding by indication.

Recurrence and Reoperation Outcomes

Documented recurrence, defined as returning symptoms with imaging evidence, occurred in 43 of 299 patients (14.4%), and 26 (8.7%) had reoperation for recurrence. All 43 recurrences came from the 231 patients with follow-up data (median, 24 months). The other 68 patients had no follow-up data. Recurrence-free survival did not differ by bowel technique (P = .431), bladder technique (P = .116), or postoperative hormonal therapy (P = .812), though the study cannot establish equivalence between approaches.

Local recurrence was documented in 4 of 178 patients after bladder shaving and 4 of 91 after rectal shaving, and in none after disc excision or segmental bowel resection. Because technique selection depended on disease characteristics, the findings do not show superior disease control with more radical surgery.

In a separate series of 1092 patients (84% with deep disease) who underwent complete excision by a single surgeon between 2009 and 2018, the estimated probability of repeat endometriosis-related surgery reached 28% at 10 years.² Of the 155 patients who had repeat surgery, 108 needed it for recurrence and 39 for assisted reproduction, and the authors noted that single-surgeon data limit generalizability.

Preoperative infertility affected 43.5% of patients, and 21.5% of them (28 of 130) had a documented postoperative pregnancy, though reproductive follow-up was incomplete, so this is not a pregnancy rate.¹

Limitations and Clinical Implications

The study was retrospective, had no staged-surgery comparison, and took place at high-volume tertiary centers, which may limit generalizability to less extensive disease. Follow-up was incomplete because many patients returned to referring physicians, and the study could not show whether one-stage excision lowers recurrence risk.

A separate group of 70 patients who had bowel surgery without anterior compartment surgery (not part of the 299) had more grade II or higher complications than 167 patients with combined anterior-posterior surgery and disc excision or segmental resection (38.6% vs 12.6%), but baseline differences prevented attributing the gap to surgical strategy.

The investigators concluded that preoperative counseling and surgical planning should account for anatomical disease extent, procedural complexity, and patient-specific goals.

References

1. Pagano F, Sík PB, Imboden S, Bokor A, Mueller MD. Perioperative morbidity and recurrence after one-stage laparoscopic resection for multicompartment deep endometriosis: a multicentre cohort study. BJOG. Published online November 2, 2026. doi:10.1111/1471-0528.70366
2. Roman H, Chanavaz-Lacheray I, Hennetier C, et al. Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series. Fertil Steril. 2023;120(4):870-879. doi:10.1016/j.fertnstert.2023.05.156