Rectal Shaving in Colorectal Endometriosis Surgery—Definition, Evidence and Variability

A structured literature search was conducted using PubMed, covering the period from 1990 to 2026. The two earliest studies included in this review, describing rectal shaving before the term itself became established in indexed publications (Reich et al., 1991 [ 6 ]; Donnez et al., 1995 [ 5 ]), fall within this search window and are discussed as original descriptive reports. The search combined the terms “rectal shaving”, “shaving”, “conservative surgery” and “endometriosis”, applied to titles and abstracts, with no language restriction, and was performed directly through the PubMed web interface; all records were exported and screened for title/abstract relevance using a predefined set of anatomical and surgical keywords (rectal, rectovaginal, bowel, colorectal, rectum, shaving, disc excision, segmental resection, nodular resection). Both prospective and retrospective surgical studies describing rectal shaving for deep infiltrating endometriosis were considered for inclusion. Eligibility was based on the following criteria: (1) involvement of rectal or colorectal endometriosis, (2) a description or definition of rectal shaving, and (3) reporting of recurrence and/or intraoperative and/or postoperative complications; publications providing only a definition of rectal shaving without recurrence or complication data were retained separately to inform Table 1 and the Discussion, but are not counted among the formally included studies shown in Figure 1 . Studies focusing exclusively on diagnostic imaging, on endometriosis at sites other than the rectum/colon, or lacking sufficient surgical detail were excluded. For all eligible publications, the methods section was examined to determine whether an explicit, anatomically anchored definition of rectal shaving (depth of excision, mucosal status, bowel lumen involvement) was provided. This review is based on a single database (PubMed); complementary searches of other databases (e.g., Embase, Cochrane Library) were not performed. Data extracted from eligible publications included definitions and terminology of rectal shaving, study design, recurrence rates, complication rates, and duration of follow-up. Results were summarised narratively and presented in tabular form to illustrate variability in definitions and reported outcomes. The search retrieved 330 records (1990–2026). After title and abstract screening using the predefined keyword set described above, 239 records were excluded—238 as addressing endometriosis topics unrelated to rectal or colorectal shaving (e.g., ovarian endometrioma, hormonal therapy, presacral neurectomy), and one (a retrospective evaluation of intraoperative proctosigmoidoscopy) as not addressing the technique under discussion—leaving 91 candidate publications assessed in full text. Of these, four were excluded as not relevant to rectal/colorectal shaving, one was excluded as addressing small-bowel rather than rectal/colorectal disease, and 55 were excluded for lacking a sufficiently explicit, anatomically anchored definition of rectal shaving and/or recurrence/complication data, leaving 31 included studies ( Figure 1 ). Of these, 19 inform the definition-evidence synthesis, and 15 report recurrence and/or complication data across 18 table entries in the quantitative synthesis; three studies contribute to both.

Deep infiltrating endometriosis of the rectum is a challenging condition, often causing dyschezia, pelvic pain, diarrhoea, constipation, bloating and reduced quality of life [ 1 , 2 ]. Surgical treatment is frequently required when symptoms persist despite medical therapy, and several operative strategies have been described, ranging from laparoscopic rectal shaving to transanal discoid rectal resection and segmental rectal resection with anastomosis [ 3 ]. Among these approaches, rectal shaving is widely performed, particularly as part of a conservative, symptom-guided surgical philosophy aiming to preserve bowel integrity whenever possible. An international consensus-based terminology defined shaving as a partial thickness excision, without entering the lumen but requiring suture of the bowel. Lesions located on the peritoneal surface (serosa) of the rectum are considered peritoneal endometriosis and not bowel endometriosis [ 4 ]. However, the term “rectal shaving” is not used consistently across the literature, and different types of endometriosis excision on the rectal wall are referred to as “rectal shaving”, despite marked differences in surgical depth and anatomical involvement of rectal wall layers. For clarity, this review uses “rectal shaving” for partial-thickness excision that preserves the mucosa, in line with the 2021 consensus terminology [ 4 ]. “Conservative surgery” is used as an umbrella term covering both shaving and disc excision, as opposed to segmental resection. Several publications on laparoscopic management of rectal endometriosis illustrate the variability in using the term “rectal shaving”. In a large series reported by Donnez et al. [ 5 ], rectal shaving was described as meticulous excision of fibrotic endometriotic tissue from the anterior rectal wall during surgery for rectovaginal disease. The authors did not clearly differentiate between serosal, muscular, or mucosal layer involvement, but describe the technique as detachment of rectal endometriotic nodules from the anterior rectal wall to reach the correct cleavage plane. Similarly, another study by Reich et al., addressing laparoscopic treatment of cul-de-sac obliteration secondary to deep fibrotic endometriosis, reported shaving as a technique applied to the rectum during restoration of the pouch of Douglas, in which excision frequently extended into the muscularis propria while deliberately avoiding opening of the rectal lumen. In both studies, the term “shaving” encompassed a wide spectrum of surgical procedures, ranging from superficial serosal excision to deep muscular dissection, without standardized anatomical or surgical criteria [ 6 ]. Roman and colleagues used a more reproducible definition. In a long-term functional outcome study, rectal shaving was described as a bowel-preserving procedure for rectal endometriosis, in contrast to colorectal resection [ 7 ]. In a dedicated series, Roman et al. described rectal shaving as complete excision of rectal deep endometriosis while preserving the rectal mucosa and avoiding intentional opening of the rectal lumen [ 8 ]. This definition clearly separates shaving from disc excision and segmental colorectal resection. In a comprehensive video article, Chou et al. demonstrated the technique as “shaving” the lesion off the mucosa, ideally without entering the bowel lumen [ 9 ]. In contrast, other authors use the term rectal shaving for the description of superficial removal of endometriotic tissue confined to the rectal serosa or include the opening of the lumen as a possible part of rectal shaving [ 10 , 11 ]. In summary, the same term includes superficial excision, deep muscular excision, and sometimes opening of the bowel lumen in the existing literature and in daily practice. This lack of standardized definition leads to poor comparability of clinical results, heterogeneity in complication rates, and represents a bias in the interpretation of recurrence rates. A clearer understanding of how rectal shaving is defined and applied in the literature is therefore essential to improve comparability of future study results.

Across the included studies, substantial heterogeneity was observed in the definition of rectal shaving, and depth of excision is not consistently defined in the methods section of the available literature. Early reports from the 1990s used the term broadly for bowel-preserving dissection of rectovaginal or rectal disease, often without a clear layer-based definition [ 5 , 6 ]. In later clinical series, shaving continued to include deep muscular excision, while preservation of the bowel lumen remained an important but not uniformly applied feature [ 11 ]. In 2016, Roman et al. provided a more reproducible anatomical definition, describing rectal shaving as complete excision of rectal endometriosis with preservation of the mucosa and without intentional opening of the bowel lumen [ 8 ]. In 2021, the international consensus by Tomassetti et al. defined shaving as partial-thickness excision without intentional opening of the bowel lumen [ 4 ]. While in 2019, Khazali et al. reported rectal shaving as part of complete excision of deep endometriosis, without a clear layer-based definition [ 12 ], in 2024 the same group referred to the consensus statement in the description of the SOSURE approach in deep endometriosis surgery and thus adopted a standardized definition of terminology [ 13 ]. The historical development shows a transition from a broadly applied bowel-preserving surgical concept toward a more anatomically defined, mucosa-sparing technique ( Table 1 ). Nowadays, although well-defined, the term rectal shaving continues to be used for a wide range of different surgical interventions on the rectal wall, including techniques in which bowel opening may occur as a consequence of deep excision [ 10 ]. Evolution of definition and terminology of rectal shaving in deep rectal endometriosis surgery. Note: Table 1 highlights the subset of included studies that specifically mention the definition/terminology of rectal shaving; three of these (Donnez & Squifflet [ 11 ], Roman et al. 2016 [ 8 ], and Collinet et al. [ 23 ]) also contribute recurrence or complication data. To assess whether adoption of the 2021 consensus terminology has improved over time, the methods sections of all eligible publications introducing or reporting a definition of rectal shaving ( Table 1 ) were examined for an explicit, anatomically anchored definition of rectal shaving, benchmarked against the Tomassetti et al. [ 4 ] terminology. Several of these publications predate the 2021 consensus and independently converge on a similar partial-thickness, mucosa-preserving, lumen-avoiding description, indicating that anatomically precise definitions of rectal shaving were achievable well before the formal consensus was published. Of the seven extracted publications published after 2021 that provided their own explicit operational definition, five (Xu et al., 2022 [ 18 ]; Gaia et al., 2023 [ 19 ]; Vallée et al., 2025 [ 20 ]; Tsuei et al., 2025 [ 21 ]; Zhang et al., 2025 [ 22 ]) describe the technique in terms broadly consistent with the consensus definition—partial-thickness excision with preservation of the mucosa—yet none explicitly cites the Tomassetti et al. [ 4 ] terminology as its source. Khazali et al. [ 13 ], in their 2024 description of the SOSURE approach, is the only identified post-2021 publication to explicitly reference the consensus terminology. Collinet et al. [ 23 ] described a shaving technique performed “as deep as possible into the thickness of the rectal wall”, occasionally requiring repair of a full-thickness defect. Publications specifically reporting recurrence after rectal shaving remain limited, and reported recurrence rates varied across the available studies ( Table 2 ). In a retrospective study of 122 patients undergoing rectal shaving, Roman et al. reported an overall recurrence rate of 4.0%. The recurrent lesions were subsequently managed by repeat shaving in 0.8%, disc excision in 0.8%, and segmental resection in 2.4% of patients [ 8 ]. In a randomized trial and its long-term follow-up studies, recurrence after conservative surgery was reported in 3.7% of patients at 5 years and 7.4% at 7 years, compared with 0% after segmental colorectal resection at both follow-up points. However, the conservative group included both rectal shaving and disc excision and therefore does not provide a shaving-specific recurrence estimate [ 24 , 25 , 26 ]. At the 10-year follow-up of the same trial cohort, recurrence was reported in 7.4% after excision versus 3.6% after segmental resection (OR 0.46, 95% CI 0.04–5.4; p = 0.54) [ 27 ]. In a systematic review and meta-analysis, Bendifallah et al. also showed that recurrence was more frequent after shaving than after disc excision or segmental resection, with rates of 8.3%, 5.7%, and 2.7%, respectively, in a subgroup analysis restricted to histologically confirmed recurrence (i.e., the histology-confirmed comparative subset of four studies within this systematic review; the review’s overall pooled recurrence rate across all 41 included studies was 8.1% for shaving, 10.4% for disc excision, and 8.6% for segmental resection, as shown separately in Table 2 ). The pooled odds ratio was 5.53 for shaving versus segmental resection (95% CI 2.33–13.12; p = 0.001) and 3.83 for shaving versus disc excision (95% CI 1.33–11.05; p = 0.01) [ 28 ]. Complication rates after rectal shaving are summarized in Table 3 . Reported complications include both intraoperative adverse events (e.g., rectal perforation and ureteral injury occurring during dissection) and postoperative complications (e.g., fistula formation, bladder atony, anastomotic or bowel-wall stenosis); the two categories are distinguished where the source studies report them separately. In a prospective study by Donnez and Squifflet, major intraoperative and early complications after rectal shaving included rectal perforation in 1.4%, ureteral injury in 0.8%, blood loss > 300 mL in 0.2%, and urinary retention in 0.8% [ 11 ]. In the largest shaving series, including 3298 patients, Donnez et al. reported major complications such as rectal perforation in 1.3%, transient ureteral retention in 0.64%, ureteral injury in 0.3%, and fecal peritonitis in 0.04% [ 29 ]. In a rectal shaving cohort using plasma energy, Marty et al. observed no intraoperative complications [ 30 ]. Postoperatively, rectovaginal fistula occurred in 0.9%, rectouterine fistula in 0.9%, and bladder atony requiring ≥3 weeks of self-catheterization in 1.8%. Roman et al. reported Clavien–Dindo grade IIIa, IIIb, IVa, and IVb complications in 0.8%, 5.7%, 1.6%, and 0.8%, respectively, and rectal fistula formation in 1.6% [ 8 ]. Comparative studies generally show a higher burden of severe complications after segmental colorectal resection than after conservative rectal surgery. Roman et al. reported Clavien–Dindo grade III complications in 22.0% after conservative surgery and in 30.3% after segmental resection, whereas bowel stenosis requiring an additional procedure was observed only after segmental resection (0% vs. 15.2%) [ 24 ]. In the three-arm cohort published by Abo et al., Clavien–Dindo grade IIIb complications occurred in 11.8% overall, with two-thirds of these events occurring after segmental resection; rectovaginal fistula was reported in 2.1% after shaving, 3.7% after discoid excision, and 5.8% after segmental resection [ 3 ]. In a multicenter study, Hudelist et al. described grade III–IV complications in 3.7% after shaving, 2.7% after discoid excision, and 7.8% after segmental resection [ 31 ]. In a single-center cohort, Bafort et al. reported Clavien–Dindo grade III complications in 1.6% after conservative surgery and 10.5% after segmental resection, though the conservative group was not limited to rectal shaving alone [ 32 ]. Similarly, Hernández Gutiérrez et al. reported severe postoperative complications in 0% after shaving, 5.0% after discoid excision, and 23.5% after segmental resection [ 33 ]. Key studies reporting complication rates after rectal shaving and comparative bowel surgery for deep endometriosis.

Although in 2021 an international consensus defined rectal shaving as partial-thickness excision with preservation of the mucosa and without intentional opening of the lumen [ 4 ], a universally accepted definition of what rectal shaving exactly means is still lacking, and different interpretations continue to be used in the literature and in daily practice. The same term is used for procedures with different surgical techniques, including superficial excision, deep mucosa-sparing excision, and full-thickness excision including intentional opening of the bowel lumen. It is noteworthy that the concept of rectal shaving has developed over time. Initially, the authors described surgery for rectovaginal disease as complete excision of nodules, without clear differentiation between the applied type of excision and excision depth [ 5 , 6 ]. These earlier studies show that the term “shaving” was initially used for a broader surgical concept rather than for a strictly defined anatomical technique. In a later prospective series, rectal shaving was still presented as a conservative surgical approach, however related to a rectal perforation rate of 1.4%, indicating that excision was not limited to superficial layers [ 11 ]. In recent reviews, Donnez and Donnez state that shaving is feasible independently of lesion size and feasible in >95% of deep rectal endometriosis cases, and describe shaving as dissection along the rectal muscularis, with bowel opening as a consequence of deep shaving [ 10 , 35 ]. This definition extends shaving toward deeper excision and overlaps with full-thickness techniques like discoid excision. In contrast, Roman et al. provide a more reproducible definition, in line with the international consensus, describing rectal shaving as excision of disease from the serosa and/or muscularis with preservation of the mucosa and avoidance of lumen opening. This definition excludes incomplete excision and distinguishes rectal shaving clearly from disc excision and segmental colorectal resection [ 8 ]. In their most recent 10-year follow-up analysis of this trial cohort, Roman et al. use “nodulectomy” as an umbrella term encompassing both shaving and disc excision, as opposed to segmental resection [ 27 ]—a terminological convention that parallels the conservative-surgery/segmental-resection distinction adopted in this review. Other authors define shaving by what it is not, when compared to disc excision and segmental resection. In most of the existing literature, a clear definition of what exactly is meant by “rectal shaving” is missing from the methods section; this also extends to large, frequently cited series that are not specifically framed as shaving studies. Bourdel et al. included patients with at least invasion of the serosa of the rectum in rectovaginal nodules exceeding 2 cm in a comparative study of different techniques in the management of rectovaginal endometriosis [ 36 ]. Since serosal disease is not considered rectal endometriosis and is not equivalent to nodules infiltrating the muscularis layer, this illustrates that the criteria used to identify a “rectal” nodule requiring surgery are inconsistently anchored to a specific anatomical depth. This pattern is not confined to older literature: as detailed in Section 3.1 , the seven identified post-2021 publications providing their own surgical definition of rectal shaving describe a technique broadly consistent with the consensus definition in substance, yet do not specify infiltration depths, nodule size, and whether suture is needed or not. Khazali et al. [ 13 ] is the only identified publication to explicitly reference the consensus by Tomassetti et al. [ 4 ]. Taken together, these findings suggest that the definitional substance of the 2021 consensus has been adopted in the literature, but also show that explicit citation of the consensus terminology as its source remains rare, and that the heterogeneity in how rectal shaving is used and reported is not a historical discussion predating standardization efforts, but a persistent feature of current publication practice. In our clinical experience, this inconsistent adoption is not confined to the published literature reviewed here: the same imprecise, non-anatomically anchored use of the term is present in conference presentations, case discussions, and everyday clinical decision-making, where “shaving” is often used as a general label for conservative, bowel-preserving surgery without further specification of excision depth. Taken together, these findings show that the term rectal shaving is used for fundamentally different procedures with differences in complication risks and recurrence rates. This likely explains the variability in reported recurrence and complication rates across studies. In summary, rectal shaving is associated with lower rates of major postoperative complications compared with disc excision or segmental colorectal resection [ 3 ]. Long-term functional outcomes, particularly regarding bowel function, appear to be more favorable after rectal shaving than after radical resection, while the risk of recurrence following rectal shaving, especially in cases of deep rectal infiltration, seems to be higher compared to disc resection and segmental resection [ 7 ]. However, recurrence estimates should be interpreted with caution given that several comparative studies combine shaving with other conservative procedures rather than reporting a shaving-specific result. As recurrence rate seems to be related to the completeness of excision of the disease and thus the depth of excision, a meaningful description of the procedure in the method section of further studies should specify the depth of excision, the resulting residual wall thickness, and whether fibrotic or endometriotic tissue was deliberately retained to maintain bowel-wall integrity, and thus completeness of excision of the nodule was achieved or not. Modern imaging enables preoperative characterization of lesion size and bowel-wall infiltration, thereby supporting classification-based surgical planning. Based on presurgical imaging and the #Enzian classification, we recently described complete nodular resection (CNR), a mucosa-sparing complete excision of the rectal nodule and surrounding muscular layer with a single-layer transversal suture adopting the rectal wall [ 37 , 38 ]. A comparable technique using laparoscopic submucosal liquid injection to facilitate separation of the muscularis from the mucosa was described by Chou et al. [ 9 ]. Intraoperative transvaginal, transrectal, or laparoscopic ultrasound may additionally help verify complete lesion excision [ 39 , 40 ], and a recent feasibility study specifically evaluated multifaceted intraoperative ultrasound to facilitate the shaving technique itself [ 41 ], while standardized early postoperative imaging could document the immediate anatomical result and provide a reference for subsequent follow-up. Without such documentation, persistent disease deliberately or inadvertently left behind may be misclassified as recurrence. Interpretation is further complicated by postoperative oedema, fibrosis, and wall duplication following shaving and suturing, which may mimic residual disease. Moreover, comparisons with discoid or segmental resection are affected by selection bias, as shaving is generally performed in smaller or technically more favorable lesions, whereas larger, multifocal, stenotic, or deeply infiltrating lesions are more often treated by bowel resection. Outcomes also remain highly operator-dependent because shaving is not a uniform procedure, and published studies use heterogeneous definitions of recurrence, ranging from recurrent symptoms or imaging abnormalities to histologically confirmed disease and reoperation. This review has several limitations. The search was restricted to a single database (PubMed) using multiple terms, and a narrative rather than a fully systematic multi-database synthesis was performed; no complementary databases (e.g., Embase, Cochrane Library) were searched. Reliance on title/abstract indexing may still have missed relevant studies that describe comparable procedures using different terminology; this risk is partly mitigated by discussion of additional relevant publications identified through targeted searching. No formal risk-of-bias or quality-appraisal tool (e.g., ROBINS-I, AMSTAR-2) was applied across the heterogeneous mix of single-center cohorts, randomized trials, and systematic reviews/meta-analyses summarized in Table 2 and Table 3 . The available evidence on rectal shaving is predominantly observational and heterogeneous in design, recurrence definition, and follow-up duration, which limits the strength of any conclusions about the comparative effectiveness of shaving versus disc excision or segmental resection. Future research, especially when comparing different surgical techniques in the management of symptomatic deep rectal endometriosis, should be based on a standardized definition of what rectal shaving exactly means. This approach would allow for better comparability of outcomes, such as complication and recurrence rates, and help overcome the uncertainty related to the term “rectal shaving”. Meaningful comparison of rectal shaving with discoid or segmental resection will require prospective studies using standardized indications, a reproducible description of the achieved excision depth, early postoperative reference imaging, and separate reporting of residual disease.

Rectal shaving is a widely used conservative surgical technique for the treatment of rectal deep infiltrating endometriosis. However, there is substantial variability in how rectal shaving is defined and performed. This limits direct comparison of recurrence and complication outcomes. While the 2021 international consensus established a formal definition of rectal shaving, the present review shows that this definition has not yet been consistently adopted in practice. A global guideline on diagnosis and treatment of rectal endometriosis, including standardized intraoperative and early postoperative imaging, would help to improve comparability of studies, support balanced, patient-centered surgical decision-making and to avoid incomplete excision and be essential to distinguish deliberately or inadvertently retained disease from true recurrence.