Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more

Purpose To compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH- SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection.

Retrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis.

100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classifica- tion was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively).

No statistically significant differences were found in the rate of digestive complications in case of total hyster - ectomy and concomitant segmental resection when performing or not preventing stoma.

Bowel endometriosis · Total hysterectomy · Segmental resection · Post-operative complications · Preventing stoma What does this study add to the clinical work Avoid the realization of PDS at the time of radical surgery for intestinal endometriosis, especially in case of endometriotic lesions not affecting the lower rectum.

Bowel endometriosis affects 5–12% of patients with endo- metriosis, with 90% of the lesions seen in the recto-sigmoid region [1–3]. Symptoms like dysmenorrhea, dyschezia, dys- pareunia, constipation, tenesmus are commonly associated with bowel endometriosis, often determining a detrimental impact on patients’ quality of life [4, 5]. In patients with any symptoms of intestinal obstruction, or in those which medical therapy was ineffective, surgi- cal treatment is considered. The three suggested surgical approaches for bowel endometriosis include the shaving technique, disc excision and segmental resection(SR). In the absence of clear agreement among surgeons, the choice of the technique depends on the site, dimension, number and percentage of lumen stenosis of the lesions [6, 7]. When a SR is performed, a protective defunctioning stoma(PDS) could be considered, even if its effectiveness * Carolina Dolci [email protected] 1 Centre Hospitalier Universitaire de Lille, Service de Chirurgie Gynécologique, 59000 Lille, France 2 Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy 3 Faculté de Médecine, Université de Lille, 59000 Lille, France 2124 Archives of Gynecology and Obstetrics (2024) 310:2123–2132 in endometriosis context remains debated[8 ]. The increase in surgical complexity, the need for a second surgery and the considerable discomfort for the patients should be also considered [9–11]. The new French guidelines for the man- agement of colorectal endometriosis consider PDS only in case of low rectal lesion and concomitant colpectomy [12]. Alternatively, an omental flap interposition(epiploplasty) between the digestive scar and the vaginal suture was pro- posed, even if it is not always feasible and its efficacy in this context was not proven [13]. The aim of the present study, therefore, was to evaluate the role of PDS on the occurrence of postoperative com- plications in patients requiring total hysterectomy and con- comitant SR(TH-SR) for intestinal endometriosis.

This retrospective study was carried out between January 2008 and January 2022 at the Gynecologic department of University Hospital of Lille, France. We included sympto- matic women affected by histologically confirmed bowel endometriosis, aged more than 18 years, with no more pregnancy desire, undergoing TH-SR. Patients submitted to subtotal hysterectomy, with malignancy at the histologic specimen, with preexistent PDS or lost at follow-up were excluded. All the included women signed a written informed consent to record their data for scientific purposes. The study was conducted in accordance with the Declaration of Hel - sinki and approved by the Ethical Review Committee of the University Hospital of Lille (CEROG 2022-GYN-1203). Data regarding patients age, medical and obstetric history, previous abdominal surgery, previous medical and surgical treatment for endometriosis, symptoms related to endome- triosis were collected from medical records. The initial diagnosis of bowel endometriosis was made through a pelvic magnetic resonance imaging (MRI). Intes- tinal endometriosis was defined as deep endometriosis with infiltration of at least the muscolaris [14]. A rectal endo- scopic sonography or computed tomography (TC) were then performed to better identify the involvement of bowel wall layers, the distance from anal marge and the percent- age of lumen stenosis. All radiological examinations were performed or at least reviewed in our institution. All the surgical indications were validated after discussion in an endometriosis multidisciplinary setting. During surgery, the abdominal and pelvic cavities were explored to identify all endometriotic lesions. Hysterec- tomy with bilateral salpingectomy with or without ova- riectomy was completed. The decision to perform ova- riectomy was based on patients age and ovarian findings. Bowel SR were performed in an interdisciplinary approach together with colorectal surgeons [8 , 15]. PDS with or without epiploplasty was performed to protect the anasto- mosis, according to intra-operative findings. All the others DIE lesions were excised, to accomplish the objective of complete surgery. Urinary tract endometriotic lesions were treated according to their anatomic extent [16]. Data including duration of surgery, blood loss, size of histological specimens, length of hospital stay, surgical complications, reoperations and hospital readmissions were retrieved from medical reports. The surgical complexity was estimated according to the American Association of Gynecologic Laparoscopists (AAGL) score from surgical reports [17]. Patients were systematically reviewed both by gyneco- logic and gastro-intestinal surgeon at 6 weeks after surgery. In case of normal follow-up, women were addressed to general gynecologists at 3 months. In case of unfavorable clinical evolution, closer follow-up with the surgeons were planned. In the case of PDS, the closure was performed after a contrast enema to exclude subclinical leaks. Based on the surgical decision to perform or not the PDS, we retrospectively divided our study population in two group: the PDS group and the non-PDS group. Surgical complications were classified according to the Clavien Dindo (CD) classification [ 18]. De-novo voiding dysfunction requiring self-catheterization lasting more than 1 month was considered as a major complication. The primary endpoint of this study was to compare the rate of surgical complication when PDS was performed or not. The secondary endpoint was the assessment of the potential risk factors in the occurrence of surgical complications. Statistical analysis Statistical Package for Social Science (SPSS) version 21.0 was used to perform data analysis. The Kolmogo- rov–Smirnov test was used to analyze the normal distribu- tion of the variables (p-value > 0.05). Continuous variables were expressed as mean and standard deviation (SD) or as median and interquartile range(IQR). For continuous vari- ables the Student’s t test (for normally distributed data) and Mann–Whitney U test (for non ‐normally distributed data) for independent samples were adopted as appropriate. For categorical variables, the statistical significance of differ - ences in distribution was tested with Pearson χ2 test or with the exact Fisher test as appropriate. The statistical analysis was conducted at a 95%confidence level and a p‐value < 0.05 was considered statistically significant. Logistic regression was applied to test the association between risk factors for intestinal complications and bladder atony. Exploratory uni- variate analyses were initially applied to all variables, and variables that had a significant association with the adopted scores at univariate analysis (95% confidence level) were 2125Archives of Gynecology and Obstetrics (2024) 310:2123–2132 eventually included in the multivariate analyses (95% con- fidence level).

During the study period, 124 women underwent TH-SR for suspected endometriosis. Of these, seven women were excluded because the suspicion of endometriosis was not confirmed at the histology, seven women were excluded because an ovarian malignancy was found at the histological specimen, two women were excluded because of preexisting PDS and eight women were lost at follow-up. The remaining 100 women were considered for the analysis. A PDS were performed in 56 women(Fig.  1). The baseline characteristics of the included women are reported in Table  1. The majority of lesions were seen in the sigmoid (70.4% in the non-PDS group and 58.9% in the PDS group, p = 0.13) and recto-sigmoid region (29.5% in the non-PDS group and 53.6.9% in the PDS group, p = 0.01). The lesions were mostly unifocal and with a median size major of 3 cm at the MRI. The intra and peri-operative data are shown in Table  2. The surgical approach was more common laparoscopic (79.5% and 73.2% respectively, p = 0.46), with 3 (5.3%, p = 0.25) laparo-conversion in the PDS group. In line with the MRI findings, the bowel lesions were mainly unifocal (75% in the non-PDS group and 58.9% in the PDS group) and seen more commonly in the sigmoid (75% in the non- PDS group and 71.4% in the PDS group, p = 0.68) and in the rectum (40.9% in the non-PDS group and 57.1% in the PDS group, p = 0.10), but a higher proportion of cecal and small-bowel lesions were found at the time of surgery (2.3% and 11.4% respectively in the non-PDS group and 7.1% and 10.7% in the PDS group). The bowel segmental resections were more common single (90.1% in the non-PDS group and 76.8% in the PDS group, p = 0.10), recto-sigmoid (84% in the non-PDS group and 85.7% in the PDS group, p = 0.82), with a mean total length of 13.7 ± 7.9 cm and 16.9 ± 11.5 cm respectively (p = 0.11). The rate of rectal resections was sig- nificantly higher in the PDS-group (p = 0.03). Ureterolysis and DIE nodules excision were the most common additional procedures performed at the time of surgery (93% and 54.5% respectively in the non-PDS group, 92.8% and 46.4% in the PDS group, p = 0.94 and p = 0.42). Ureteral reimplantation were only performed in the PDS group (p = 0.008). There was not significant difference in the performing of the epi- ploplasty between the two groups (p = 0.79), whereas the placement of abdominal drainage was significantly more common in the PDS group (p = 0.001). The mean opera- tive time, the mean AAGL scores and the mean length of hospital stay were significantly higher in the PDS group (p = 0.002). No significant difference was found between the two groups in the rate of grade I and grade II complications, whereas the rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03), as reported in Table  3. No grade IV and V complications were reported. Among the diges- tive complications, we recorded one case of anastomosis leakage in the non PDS group (2.3%), one case of recto- vaginal fistula in the non-PDS group (1.8%) and 4 cases of anastomosis stenosis in the PDS group (7.1%). The anastomosis leakage required reoperation under general anesthesia with peritoneal toilette and the confection of a defunctioning stoma. The anastomosis stenosis needed dilatation through a rectosigmoidscopy under general anesthesia. The recto-vaginal fistula required a laparoto- mic reoperation under general anesthesia with colo-anal stoma in two steps according to Baulieux technique [19] and a new vaginal suture. The median timing of ileostomy closure in the PDS group was 8 week [IQR 7–10] and the median time of follow-up was 4 (3–8.25) and 6 (4–14) months in the non PDS group and PDS group respectively (p = 0.06). Persisting bladder atony requiring self-catheterization over one month after surgery was the most common dis- turb (4.6% in the non-PDS group and 7.1% in the PDS- group, p = 0.58). The exploratory univariate analyses evaluating risk factors for intestinal complications (Table  4) found not significant associations except for the MRI distance of digestive lesion from anal margin (p = 0.04) and the length of bowel resection (p = 0.06), but at the multivari- ate analysis, only the MRI distance of digestive lesion from anal margin was significative (p = 0.04). The explor- atory univariate analyses and multivariate analysis evalu - ating risk factors for persistent bladder atony, Clavien- Dindo IIIA and IIIB complications (Table  5) found not significant associations except for the MRI distance of digestive lesion from anal margin (p = 0.06).

Our results suggested that, in case of TH-SR for endome- triosis, performing PDS does not reduce the risk of severe peri-operative (grade IIIA and IIIB according to CD clas- sification) complications, especially digestive complications. These results are more remarkable if we consider the con- text of concomitant colpectomy, reported to be one of the main risk factors for digestive complications after intestinal resection, together with low rectal lesions (less than 5 cm from the anal verge) [20]. The rate of grade III complications was higher in PDS group. This difference can be explained by the more 2126 Archives of Gynecology and Obstetrics (2024) 310:2123–2132 complicated surgical interventions in this group, demon- strated by the longer operative time, the needs of ureteral reimplantations, the significantly higher number of rectal lesions (p = 0.03), the higher AAGL scores, the longer hospi- tal stay, and by the presence of stoma itself. Indeed, specific stoma-related complications include high output and electro- lyte disturbance, skin complications and parastomal hernias. Indeed, concerns about the medium/longer term risks associ- ated with PDS, including functional digestive complications due to the microbiota intestinal alterations and long-term sequelae of high output (e.g., chronic kidney disease), are rising also in the field of rectal cancer surgery [21]. Very few data exist in literature on the benefices of per - forming PDS in the case of SR at the time of TH for endo- metriosis. Laskmann in 2006 [22] and Pikron et al. in 2009 described the feasibility of laparoscopic colorectal resec- tion at the time of TH for endometriosis in a single patient respectively [23]. In a retrospective study on 29 sympto- matic women affected by colorectal endometriosis, Darai et al. confirmed the feasibility of laparoscopic TH-SR, Fig. 1 Strengthening the reporting of observational studies in epidemiology (STROBE) flow chart of study design. *TH-RS: total hysterectomy and concomitant segmental resection, PDS protective defunctiongn stoma 2127Archives of Gynecology and Obstetrics (2024) 310:2123–2132 performing only 3 PDS. One case of anastomosis leakage was registered, but it was not specified if the patients was submitted to PDS or not [24]. Lim et al., in 2011 carried out a retrospective study on 18 women submitted to low anterior resection with sigmoid rectal anastomosis and TH for endometriosis comparing the robotic-assisted approach to the laparotomic approach. The authors did not perform PDS and registered two cases of recto-vaginal fistula only in the laparotomic group, demonstrating the feasibility of robotic approach [25]. In 2019, Boudy et al. performed a retrospective study on 27 patients undergone laparoscopic TH-SR for endometriosis, performing a prevescical peri- toneum interposition between vagina and digestive scars, with only a case of recto-vaginal fistula registered [13]. In 2022, Roman et al. retrospectively compared postopera- tive complications and rectovaginal fistula rate in women undergoing excision of rectovaginal endometriosis requir - ing concomitant excision of rectum and vagina during two time periods with differing policies for preventive stoma confection. No significant differences were found concern - ing risk of rectovaginal fistula (9.2% and 11.1%, p = 0.80) during the first and the second period [26]. Table 1 Characteristic of the study population at baseline SD: standard deviation; IQR: interquartile range; MRI: magnetic resonance imaging; TDM: tomodensiometry Non ileostomy (n = 44) Ileostomy (n = 56) p value Age, years, mean, ± SD 41.4 ± 5.1 40.4 ± 5.0 0.30 Parous women, n (%) 33 (75) 33 (58.9) 0.09 Parity, median (IQR) 2 (1–2) 2 (1–2) 0.51 Cesarean section, n (%) 16 (36.4) 9 (16.1) 0.02 Previous gynecological surgery, n (%)  1 surgery 31 (70.4) 43 (76.8) 0.47   ≥ 2 surgeries 17 (38.6) 23 (41.1) 0.80 Previous endometriosis surgeries, n (%) 24 (54.5) 32 (57.1) 0.79  1 Surgery 16 (36.4) 16 (28.6) 0.40   ≥ 2 surgeries 8 (18.2) 16 (28.6) 0.22   ≥ 1 laparotomy 6 (13.6) 14 (25) 0.15 Symptoms, n (%)  Dysmenorrhea 23 (52.3) 36 (64.3) 0.22  Dyspareunia 18 (40.9) 24 (42.8) 0.84  Chronic pelvic pain 30 (68.2) 33 (58.9) 0.34  Dysuria 12 (27.3) 11 (19.6) 0.36  Dyschezia 15 (34.1) 16 (28.6) 0.55  Alternance constipation/diarrhea 23 (52.3) 23 (41,1) 0.26  Occlusion/subocclusion 4 (9.1) 3 (5.3) 0.69  Abnormal vaginal bleeding 18 (40.9) 14 (25) 0.09 MRI number of digestive lesions, n (%)  No lesion 2 (4.5) 0 (0) 0.19  1 lesion 33 (75) 36 (64.2) 0.25  2 lesions 9 (20.4) 19 (33.9) 0.13  3 lesions 0 (0) 1 (1.8) 0.99 MRI localization of digestive lesions, n (%)  Rectum 5 (11.4) 11 (19.6) 0.26  Rectum-sigma 13 (29.5) 30 (53.6) 0.01  Sigma 31 (70.4) 33 (58.9) 0.13  Colon 1 (2.3) 0 (0) 0.44  Cecum 1 (2.3) 1 (1.8) 0.99  Small bowel 0 (0) 1 (1.8) 0.99 MRI size of digestive lesions, mm, median (IQR) 35 (25.25–47.75) 32 (23–50) 0.80 MRI distance of digestive lesion from anal margin, cm, mean ± SD 15.52 ± 4.1 13.77 ± 4.9 0.12 ColoTDM digestive lesion with stenosis ≥ 50%, n (%) 8 (18.2) 21 (37.5) 0.03 2128 Archives of Gynecology and Obstetrics (2024) 310:2123–2132 Therefore, to our knowledge, this study represents the largest cohort in literature on this topic and the first study aiming to evaluate the role of performing PDS in terms of surgical complications when a radical surgery for intestinal endometriosis was realized. Demonstrating the absence of significant differences in the rate of digestive complications when performing PDS, it is possible to exclude its presumed protective role and avoid its realization in case of radical sur- gery for intestinal endometriosis, at least for lesions above the rectum. Additionally, all the included patients received a complete preoperative imaging work-up by experienced radiologists, the decision to operate all our patients was discussed in a multidisciplinary fashion and all the surgical interventions Table 2 Intra- and peri- operative characteristics of the study population SD: standard deviation; American Association of Gynecological Laparoscopists Non ileostomy (n = 44) Ileostomy (n = 56) p value Laparoscopy, n (%) 35 (79.5) 41 (73.2) 0.46 Laparotomy, n (%) 7 (15.9) 12 (21.4) 0.59 Robotic, n (%) 2 (4.6) 3 (5.3) 0.85 Laparotomic conversion, n (%) 0 (0) 3 (5.3) 0.25 Number of intraoperative bowel lesions, n (%)  1 lesion 33 (75) 33 (58.9) 0.21  2 lesions 9 (20.4) 17 (30.4)  3 lesions 2 (4.6) 6 (10.7) Localization of intraoperative bowel lesions, n (%) 18 (40.9) 32 (57.1) 0.10  Rectum 33 (75) 40 (71.4) 0.68  Sigma 1 (2.3) 4 (7.1) 0.38  Cecum 0 (0) 1 (1.8) 0.99  Appendix 5 (11.4) 6 (10.7) 0.91  Small bowel Number of bowel resection, n (%) 0.10  Single resection 40 (90.1) 43 (76.8)  Double resection 4 (9.9) 13 (23.2) Localization of bowel resection, n (%)  Rectum 0 (0) 6 (10.7) 0.03  Rectum-sigma 37 (84) 48 (85.7) 0.82  Sigma 6 (13.6) 3 (5.3) 0.17  Ileo-cecal 3 (6.8) 10 (17.8) 0.13  Small bowel 2 (4.5) 2 (3.6) 0.99 Intestinal resection total length, cm, mean ± SD 13.7 ± 7.9 16.9 ± 11.5 0.11 Other surgeries, n (%)  Ureterolysis 41 (93) 52 (92.8) 0.94  Ureteral reimplantation 0 (0) 8 (14.3) 0.008  Partial cystectomy 0 (0) 3 (5.3) 0.25  Exeresis of DIE nodule 24 (54.5) 26 (46.4) 0.42  Rectal shaving 10 (22.7) 5 (8.9) 0.06  Rectal discoid resection 0 (0) 1 (1.8) 0.99  Appendicectomy 4 (9.1) 3 (5.3) 0.69  Colpectomy 3 (6.8) 9 (16.1) 0.21 Epiploplasty, n (%) 24 (54.5) 32 (57.1) 0.79 Abdominal drainage, n (%) 17 (38.6) 39 (69.6) 0.001 Operative time, min, mean ± SD 327.3 ± 74.9 392.7 ± 85.7 0.002 AAGL score, mean ± SD 39.3 ± 10.42 47.6 ± 14.0 0.002 AAGL stage, n (%) 0.58  Stage III 2 (4.6) 1 (1.8)  Stage IV 42 (95.4) 55 (98.2) Length of hospital stay, days, mean ± SD 6.2 ± 3.0 7.8 ± 3.6 0.02 2129Archives of Gynecology and Obstetrics (2024) 310:2123–2132 were performed in an endometriosis referral center by expert gynecologic surgeons in collaboration with the colorectal surgery team. Other strengths of our study are the strict inclusion and exclusion criteria, the long duration of follow- up and low rate of patients lost at follow-up. The main limitations of our study are the retrospective design with all its intrinsic issues and the monocentric Table 3 Clavien-Dindo classification of post-operative complications. Number of women presenting complications (n, %), and raw number of complications (n, %) Grade Non ileostomy (n = 44) Ileostomy (n = 56) Treatment p value Grade I, n (%) 5 (11.4) 10 (17.8) 0.12  Incomplete cicatrisation of the anastomosis 0 (0) 1 (1.8) Delayed closure of ileostomy  Compartmental syndrome 1 (2.3) Hydration  Rhabdomyolysis 0 (0) Hydration  Functional ileum 0 (0) Conservative treatment  Deficit brachial plexus 0 (0) Spontaneous regression  Neural symptom s lower limbs 0 (0) Physiotherapy  Haematuria 0 (0) Bladder lavages  Fever ndd 1 (2.3) Antipyretics  Vault vaginal ulcer 1 (2.3) Conservative treatment  Vaginal granuloma 1 (2.3) Conservative treatment  Hypokalaemia 1 (2.3) Electrolytes  Abdominal wall hematoma 0 (0) 1 (1.8) Conservative treatment Grade II, n (%) 13 (29.5) 22 (39.3) 0.31  Functional ileum 2 (4.6) 8 (14.3) Nasogastric tube  Acute pyelonephritis 2 (4.6) 2 (3.6) Antibiotics  Inferior urinary tract infection 4 (9.1) 7 (12.5) Antibiotics  Bladder injury 0 (0) 1 (1.8) Indwelling catheter  Bladder atony 5 (11.4) 7 (12.5) Indwelling/intermittent catheter  Adrenal insufficiency 1 (2.3) 0 (0) Cortisone  Postoperative anaemia 1 (2.3) 4 (7.1) Martial therapy/Transfusion  Deep venous thrombosis 0 (0) 1 (1.8) Anticoagulant  Vena porta thrombosis 0 (0) 1 (1.8) Anticoagulant  Abdominal wall infection 1 (2.3) 7 (12.5) Antibiotics Grade III, n (%) 3 (6.8) 13 (23.2) 0.03  Grade III A 0 (0) 1 (1.8) Nasogas 0.99   Atelectasis 0 (0) 1 (1.8) Fibroscopic pulmonary expansion  Grade III B 3 (6.8) 12 (16.1) 0.05   Ureteral fistula 1 (2.3) 0 (0) Ureteral resection, vesico-ureteral reimplantation and double J   Ureteral injury 0 (0) 1 (1.8) Ureteral resection, vesico-ureteral reimplantation and double J   Umbilical hernia and sub-occlusion 1 (2.3) 0 (0) Hernioplasty   Recto-vaginal fistula 0 (0) 1 (1.8) Surgical reparation   Anastomosis leakage 1 (2.3) 0 (0) Surgical reparation   Anastomosis stenosis 0 (0) 4 (7.1) Dilatation or bowel resection with anastomosis   Ileostomy herniation 0 (0) 4 (7.1) Hernioplasty at time of ileostomy closure   Hematoma of the ileostomy site 0 (0) 1 (1.8) Drainage   Abdominal wall abscess 0 (0) 1 (1.8) Drainage   Presacral abscess 0 (0) 1 (1.8) Drainage  Compartmental syndrome 0 (0) 1 (1.8)) Fasciotomy  Pneumothorax 0 (0) 1 (1.8) Fibroscopic Pulmonary drainage 2130 Archives of Gynecology and Obstetrics (2024) 310:2123–2132 setting. The long study period over than 10 years is another important limitation of the study, because potentially respon- sible for difference in patients management over time, but it was necessary to reach our sample size. In addition, in the absence of randomization, the decision to perform PDS was not random. Based on the population’s surgical char - acteristics, PDS was significantly more performed in case of rectal resection and, even if not significantly, in case of colpectomy. Therefore, the interest of the PDS as a preven- tive measure in the event of a rectal resection cannot be assessed due to the systematic use of a stoma in these cases.

In the absence of clear guidelines in the management of patients undergone TH-SR, our results suggest the absence of significant differences in the rate of digestive complica- tions when performing or not PDS, even if the utility of PDS in low rectal lesion was impossible to estimate. Thus, it is possible to exclude the presumed protective role of PDS and avoid its realization at the time of radical surgery for intes- tinal endometriosis, especially in case of lesions not affect- ing the lower rectum. Larger, randomized studies reporting Table 4 Risk factors for intestinal complications (recto-vaginal fistula, anastomosis leakage anastomosis stenosis) MRI: magnetic resonance imaging; TDM: tomodensiometry Univariate Multivariate HR p-value HR p-value Age, years 0.9 (0.8–1.1) 0.44 Previous gynecological surgery ≥ 2 0.2 (0.1–1.4) 0.18 Previous endometriosis surgery 0.5 (0.1–1.9) 0.44 ColoTDM digestive lesion with stenosis ≥ 50% 3.1 (0.8–11.5) 0.15 MRI distance of digestive lesion from anal margin ≤ 10 cm 5.6 (1.4–21.8) 0.04 5.9 (1.1–32.4) 0.03 Laparotomic approach 0.6 (0.1–3.5) 0.61 Colpectomy 1.3 (0.2–8.9) 0.77 Rectal shaving and discoid resection 1.2 (0.2–7.9) 0.84 ≥ 2 Intraoperative intestinal localization 0.8 (0.2–3.2) 0.75 ≥ 2 Intestinal resection 0.8 (0.1–5.2) 0.84 Total resection length, cm 1.0 (1.0–1.1) 0.06 1.0 (0.9–1.1) 0.06 Ileostomy 5.2 (0.8–31.5) 0.13 Epiploplasty 0.6 (0.1–2.1) 0.47 Drainage 1.0 (0.2–3.9) 0.94 Table 5 Risk factors for persistent bladder atony and Clavien-Dindo IIIA and IIIB grade MRI: magnetic resonance imaging; TDM: tomodensiometry Univariate Multivariate HR p-value HR p-value Age, years 0.9 (0.9–1.0) 0.19 Previous gynecological surgery ≥ 2 0.5 (0.2–1.3) 0.23 Previous endometriosis surgery 1.3 (0.6–2.9) 0.61 ColoTDM digestive lesion with stenosis ≥ 50% 1.4 (0.6–3.2) 0.50 MRI distance of digestive lesion from anal margin ≤ 10 cm 3.5 (1.3–9.7) 0.04 3.5 (1.1–11.7) 0.04 Laparotomic approach 1.6 (0.6–3.9) 0.41 Ureterolysis 1.9 (0.3–11.8) 0.54 DIE excision 1.8 (0.8–4.2) 0.22 Colpectomy 0.8 (0.2–3.1) 0.80 Rectal shaving and discoid resection 0.7 (0.2–2.8) 0.69 ≥ 2 Intraoperative intestinal localization 0.9 (0.4–2.3) 0.94 ≥ 2 Intestinal resection 0.4 (0.1–1.7) 0.31 Total resection length, cm 1.0 (0.9–1.1) 0.11 2131Archives of Gynecology and Obstetrics (2024) 310:2123–2132 post-operative complications after performing TH-SR with or without PDS are required. Author contributions All authors contributed to the study conception and design. Conceptualization was performed by Rubod C; project administration was realized by Rubod C, Kerbage Y and Cosson M;

preparation was performed by Kerbage Y and Dolci C; data collection was performed by Dolci C; data analysis was performed by Ruffolo AF; the first draft of the manuscript was written by Dolci C and Ruffolo AF; editing was performed by Rubod C, Gandon A and Kerb- age Y. All authors commented on previous versions of the manuscript. All authors read and approved the final version of the manuscript. Funding Open access funding provided by Centre Hospitalier Uni- versitaire de Lille. Data availability The datasets analyzed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request. Declarations Conflict of interest The authors have no relevant financial or non-fi- nancial interests to disclose. Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

1. Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: criti- cal factors to consider before management. Hum Reprod Update 21(3):329–339 2. Nezhat C, Li A, Falik R, Copeland D, Razavi G, Shakib A, Mihai- lide C, Bamford H, DiFrancesco L, Tazuke S, Ghanouni P, Rivas H, Nezhat A, Nezhat C, Nezhat F (2018) Bowel endometriosis: diagnosis and management. Am J Obstet Gynecol 218(6):549–562 3. Rossini R, Lisi G, Pesci A, Ceccaroni M, Zamboni G, Gentile I, Rettore L, Ruffo G (2018) Depth of intestinal wall infiltration and clinical presentation of deep infiltrating endometriosis: evalua- tion of 553 consecutive cases. J Laparoendosc Adv Surg Tech A 28(2):152–156 4. Donnez O, Roman H (2017) Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resec- tion? Fertil Steril 108(6):931–942 5. van Eickels D, Schick M, Germeyer A, Rösner S, Strowitzki T, Wischmann T, Ditzen B (2024) Predictors of partnership and sexual satisfaction and dyadic effects in couples affected by endo- metriosis and infertility. Arch Gynecol Obstet. https:// doi. org/ 10. 1007/ s00404- 024- 07516-z 6. Alborzi S, Roman H, Askary E, Poordast T, Shahraki MH, Alborzi S, Hesam Abadi AK, Najar Kolaii EH (2022) Colorectal endome- triosis: diagnosis, surgical strategies and post-operative complica- tions. Front Surg 4(9):978326 7. Belghiti J, Ballester M, Zilberman S, Thomin A, Zacharopoulou C, Bazot M, Thomassin-Naggara I, Daraï E (2014) Role of protec- tive defunctioning stoma in colorectal resection for endometriosis. J Minim Invasive Gynecol 21(3):472–479 8. Pereira RM, Zanatta A, Preti CD, de Paula FJ, da Motta EL, Serafini PC (2009) Should the gynecologist perform laparoscopic bowel resection to treat endometriosis? Results over 7 years in 168 patients. J Minim Invasive Gynecol 16(4):472–479 9. Ribeiro PA, Rodrigues FC, Kehdi IP, Rossini L, Abdalla HS, Donadio N, Aoki T (2006) Laparoscopic resection of intestinal endometriosis: a 5-year experience. J Minim Invasive Gynecol 13(5):442–446 10. Meuleman C, Tomassetti C, D’Hooghe TM (2012) Clinical out- come after laparoscopic radical excision of endometriosis and lap- aroscopic segmental bowel resection. Curr Opin Obstet Gynecol 24(4):245–252 11. Agnifili A, Schietroma M, Carloni A, Mattucci S, Caterino G, Lygidakis NJ, Carlei F (2004) The value of omentoplasty in protecting colorectal anastomosis from leakage. A prospec - tive randomized study in 126 patients. Hepatogastroenterology Nov-Dec;51(60):1694–7 12. Darai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry S, Bazot M (2005) Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Am J Obstet Gynecol 192(2):394–400 13. Boudy AS, Vesale E, Arfi A, Owen C, Jayot A, Zilberman S, Bendifallah S, Darai E (2020) Prevesical peritoneum interposi- tion to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: results of a pilot study. J Gynecol Obstet Hum Reprod 49(2):101649 14. Bazot M, Daraï E (2017) Diagnosis of deep endometriosis: clini- cal examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril 108(6):886–894 15. Weyl A, Sevy V, Lepage B, Vidal F, Kirzin S, Legac YT, Lesourd F, Gosset A, Capdet J, Leguevaque P, Bournet B, Lenfant F, Bri- erre T, Gornes H, Buscail E, Chantalat E (2023) Study of postop- erative complications after the implementation of a multidiscipli- nary care pathway for patients with digestive endometriosis. Arch Gynecol Obstet 307(5):1459–1468 16. Dousset B, Leconte M, Borghese B, Millischer AE, Roseau G, Arkwright S, Chapron C (2010) Complete surgery for low rectal endometriosis: long-term results of a 100-case prospective study. Ann Surg 251(5):887–895 17. Abrao MS, Andres MP, Miller CE, Gingold JA, Rius M, Neto JS, Carmona F (2021) AAGL 2021 Endometriosis classification: an anatomy-based surgical complexity score. J Minim Invasive Gynecol 28(11):1941-1950.e1 18. Dindo D, Demartines N, Clavien PA (2004) Classification of sur- gical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213 19. Olagne E, Baulieux J, de la Roche E, Adham M, Berthoux N, Bourdeix O, Gerard JP, Ducerf C (2000) Functional results of delayed coloanal anastomosis after preoperative radiotherapy for lower third rectal cancer. J Am Coll Surg 191(6):643–649 20. Akladios C, Messori P, Faller E, Puga M, Afors K, Leroy J, Wat- tiez A (2015) Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis? J Minim Invasive Gynecol 22(1):103–109 21. Denost Q, Sylla D, Fleming C, Maillou-Martinaud H, Preaubert- Hayes N, Benard A, GRECCAR group (2023) A phase III ran- domized trial evaluating the quality of life impact of a tailored 2132 Archives of Gynecology and Obstetrics (2024) 310:2123–2132 versus systematic use of defunctioning ileostomy following total mesorectal excision for rectal cancer-GRECCAR 17 trial protocol. Colorectal Dis 25(3):443–452 22. Lakshman N, Chang R, Ho Y (2006) Laparoscopic combined rectal anterior resection and total hysterectomy with bilateral salpingo-oophorectomy. Tech Coloproctol 10(4):350–352 23. Pickron TB, Cooper J (2009) Laparoscopic hysterectomy and ileocecal resection for treatment of endometriosis. JSLS 13(2):224–225 24. Daraï E, Ballester M, Chereau E, Coutant C, Rouzier R, Wafo E (2010) Laparoscopic versus laparotomic radical en bloc hyster - ectomy and colorectal resection for endometriosis. Surg Endosc 24(12):3060–3067 25. Lim PC, Kang E, Parkdo H (2011) Robot-assisted total intra- corporeal low anterior resection with primary anastomosis and radical dissection for treatment of stage IV endometriosis with bowel involvement: morbidity and its outcome. J Robot Surg 5(4):273–278 26. Roman H, Dennis T, Forestier D, François MO, Assenat V, Cha- navaz-Lacheray I, Denost Q, Merlot B (2023) Excision of deep rectovaginal endometriosis nodules with large infiltration of both rectum and vagina: what is a reasonable rate of preventive stoma? A comparative study. J Minim Invasive Gynecol 30(2):147–155 Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.