Objective To determine the long term response, quality of life and levels of pain following the radical excision of rectovaginal endometriosis. Design A cohort study.Setting A tertiary referral centre for the management of advanced endometriosis.Sample All patients who had undergone radical resection.Methods Case note review and patient questionnaire.Main outcome measures Surgical complications. Overall improvement. Dysmenorrhoea, dyspareunia, dyschezia and chronic pain were measured using a visual analogue scale. Quality of life was measured using the EQ-5D questionnaire. Results Twelve radical resections were performed by laparotomy, 48 by laparoscopy. Ten patients had a hysterectomy. Forty-eight patients underwent shaving of the pre-rectal fascia, two had a disc resection of the rectum, 10 had an anterior rectal resection. Two patients required a colostomy and two needed subsequent dilation of a stenosed anastomosis. Forty-four of the first 46 patients replied. The median follow up period was 12 months (range 2 to 22 months) and 86% (38/44) reported an improvement or whom 27 (61%) had a good response (pain completely gone or greatly improved). Patients having a hysterectomy or a disc or segmental resection of the rectum reported a good response and had a normal quality of life. Quality of life scores in the study group overall were lower than the background population. Conclusions Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.

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105 See O'Brien et al, National Action Plans: A Toolkit', above n 14, ch 6, for illustrative guidance on how, in practical terms, inclusive, participatory NAP processes might be secured. 106 For such criticisms in relation to UN treaty monitoring bodies, see literature reviewed by O'Flaherty and O'Brien, above n 11. 107 These arguments are also advanced by De Schutter, above n 52, 57, and Cassel and Ramasastry, above n 51, 24 5. For an overview of literature suggesting why a framework convention rather than a traditional command and control' treaty model would be likely to deliver such outcomes, drawn from social theory, public administration, regulation theory and international relations, see O'Brien, Human Rights and Transnational Corporations, above n 52, ch 6 (Multi-level Governance').

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