Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign

Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

Noninvasive diagnostic imaging for endometriosis part 1: a systematic review of recent developments in ultrasound, combination imaging, and artificial intelligence

Endometriosis affects 1 in 9 women and those assigned female at birth. However, it takes 6.4 years to diagnose using the conventional standard of laparoscopy. Noninvasive imaging enables a timelier diagnosis, reducing diagnostic delay as well as the risk and expense of surgery. This review updates the exponentially increasing literature exploring the diagnostic value of endometriosis specialist transvaginal ultrasound (eTVUS), combinations of eTVUS and specialist magnetic resonance imaging, and artificial intelligence. Concentrating on literature that emerged after the publication of the IDEA consensus in 2016, we identified 6192 publications and reviewed 49 studies focused on diagnosing endometriosis using emerging imaging techniques. The diagnostic performance of eTVUS continues to improve but there are still limitations. eTVUS reliably detects ovarian endometriomas, shows high specificity for deep endometriosis and should be considered diagnostic. However, a negative scan cannot preclude endometriosis as eTVUS shows moderate sensitivity scores for deep endometriosis, with the sonographic evaluation of superficial endometriosis still in its infancy. The fast-growing area of artificial intelligence in endometriosis detection is still evolving, but shows great promise, particularly in the area of combined multimodal techniques. We finalize our commentary by exploring the implications of practice change for surgeons, sonographers, radiologists, and fertility specialists. Direct benefits for endometriosis patients include reduced diagnostic delay, better access to targeted therapeutics, higher quality operative procedures, and improved fertility treatment plans.

CAR Practice Statement on Advanced Pelvic Ultrasound for Endometriosis

The Canadian Association of Radiologists (CAR) Endometriosis Working Group was tasked with providing guidance and benchmarks to ensure the quality of technique and interpretation for advanced imaging modalities associated with diagnosing endometriosis. This practice statement provides an overview of the state of the art of advanced pelvic ultrasound in the diagnosis and mapping of pelvic endometriosis. While acknowledging that advanced pelvic ultrasound in some practices falls within the scope of clinical colleagues rather than imaging departments, the statement seeks to guide radiologists interested in implementing these techniques into their practice for patients referred for evaluation and diagnosis of endometriosis. The statement covers indications, some components of the ultrasound assessment and technique, reporting, and recommendations for starting an ultrasound endometriosis evaluation program.

Vaginal leiomyoma: Advantages of clinical sonovaginography and ultrasound dynamic evaluation of uterine cervix-related lesions

Evaluation of vaginal leiomyoma by dynamic transvaginal ultrasound improves the diagnosis, with the impact on surgical planning, and surgical outcomes. Sonovaginography using three-dimensional ultrasound allows the assessment of spatial relationship between the cervix and the tumor.

Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study

BACKGROUND

To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions.

METHODS

This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery.

RESULTS

Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0 years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002).

CONCLUSIONS

Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.

Cervical sliding sign at second trimester in the prediction of early preterm birth in twin pregnancy

OBJECTIVE

To examine the cervical sliding sign (CSS) alongside cervical length (CL) in twin pregnancies to predict preterm birth (PB).

METHODS

Twin pregnancies (n = 37) with no known risk factor for PB were included in this prospective study. CSS was defined as the ultrasonographic finding in which the anterior lip of the cervix slides over the posterior lip with gentle and continuous pressure application. The CSS and CL measurements were held in the second trimester. Early PB was defined as the birth of the fetus before 32 weeks of gestation. The patients were divided into two groups as CSS-positive and CSS-negative.

RESULTS

Whereas 11 (29.7%) of the twin pregnancies were CSS-positive, 26 (70.3%) were CSS-negative. CSS positivity had a sensitivity of 75.0%, a specificity of 82.2%, a positive predictive value of 54.5%, and a negative predictive value of 92.3% to predict early PB. Multivariate logistic regression analysis revealed that CSS positivity was the only significant independent factor related to early PB.

CONCLUSION

CSS was shown to be superior to CL in providing a better insight to predict early PB. CSS evaluation should be performed in twin pregnancies.

Diagnosis of Endometriosis by Transvaginal Ultrasound: An Online Survey of Gynecologists Practising in Greece

Accurate diagnosis and assessment of endometriosis by transvaginal ultrasound scan (TVS) can be challenging. We performed an online survey of specialist gynecologists who perform TVS on a regular basis regarding their views as well as clinical experience on the use of TVS in the diagnosis of endometrioma and deep endometriosis (DE). We collected 64 responses. Sixty-one participants (95.31%) answered that they can confidently diagnose endometrioma by TVS "always" or "most of the time". With the exception of DE of the recto-vaginal septum/posterior vaginal vault, for all other DE locations, more than 50% of participants felt that they can "rarely" or "never" diagnose it by TVS in their own clinical practice. Forty-two participants (65.6%) stated that additional, specialized training is required for the diagnosis of endometrioma. When asked about a diagnosis of DE, 58 participants (90.6%) felt that the same is required. The only statistically significant association was between the number of TVSs performed per year and the clinician's ability to diagnose bowel DE in their practice. The answers to all other questions did not differ significantly based on professional status, years of experience post-residency, or number of TVSs per year. Our results demonstrate the delayed adoption of novel diagnostic approaches in endometriosis and confirm the urgent need for specialized ultrasound training.

Early noninvasive diagnosis of endometriosis: dysmenorrhea and specific ultrasound findings are important indicators in young women

OBJECTIVES

To diagnose endometriosis in young patients ≤25y with severe dysmenorrhea through specific ultrasonographic examination findings and to correlate the symptoms to its different forms: ovarian, deep infiltrating endometriosis, and adenomyosis.

DESIGN

A retrospective observational study.

SETTING

University Hospital.

PATIENT(S)

Women aged 12-25 years with severe dysmenorrhea and a visual analog scale score ≥7.

INTERVENTION(S)

This study included 371 women aged 12-25 years referred to our gynecological ultrasound (US) Unit between January 2016 and December 2021 with severe dysmenorrhea and a visual analog scale score ≥7. Two dimensional, 3 dimensional, and power Doppler US pelvic examinations (transvaginal or transrectal in presexually active girls) were performed on all patients. Medical history and symptoms were collected routinely for each patient before the scan.

MAIN OUTCOME MEASURE(S)

All possible locations of endometriosis, isolated or combined occurrence, were evaluated, and recorded using an US dedicated mapping sheet. Painful symptoms were evaluated by visual analog scale and correlated to the different endometriosis forms.

RESULT(S)

At least one US endometriosis feature was identified in 131 (35.3%) patients, whereas the US findings of 170 (45.8%) were normal despite the referred dysmenorrhea. Of the 131 patients with endometriosis, ovarian endometrioma was found in 54 (41.2%), and 22 (16.8%) had an isolated endometrioma. Adenomyosis was detected in 67 (51.1%) patients, and 28 (21.4%) showed its isolated indications. Posterior deep infiltrating endometriosis was found in 70 (53.4%) patients, and uterosacral ligament (USL) fibrotic thickening was found in 63 (48.1%). In 23 patients, the USL lesion was completely isolated. The combined occurrence of dysmenorrhea with dyspareunia, bowel symptoms, and heavy menstrual bleeding increases the presence of endometriosis up to 59%, 63%, and 45%, respectively.

CONCLUSION(S)

In young patients with severe dysmenorrhea, the US-based detection rate of pelvic endometriosis was one-third. USL fibrotic thickening and mild adenomyosis are often the only findings, so an accurate pelvic US scan can provide an early diagnosis by identifying small endometriotic lesions. Young patients with dysmenorrhea should be referred to an expert sonographer to minimize the delay between the onset of symptoms and diagnosis.

Endometriosis: A multimodal imaging review

Endometriosis is a chronic inflammatory disorder characterized endometrial-like tissue present outside of the uterus, affecting approximately 10% of reproductive age women. It is associated with abdomino-pelvic pain, infertility and other non - gynecologic symptoms, making it a challenging diagnosis. Several guidelines have been developed by different international societies to diagnose and classify endometriosis, yet areas of controversy and uncertainty remains. Transvaginal ultrasound (TV-US) is the first-line imaging modality used to identify endometriosis due to its accessibility and cost-efficacy. Enhanced sonographic techniques are emerging as a dedicated technique to evaluate deep infiltrating endometriosis (DIE), depending on the expertise of the sonographer as well as the location of the lesions. MRI is an ideal complementary modality to ultrasonography for pre-operative planning as it allows for a larger field-of-view when required and it has high levels of reproducibility and tolerability. Typically, endometriotic lesions appear hypoechoic on ultrasonography. On MRI, classical features include DIE T2 hypointensity, endometrioma T2 hypointensity and T1 hyperintensity, while superficial peritoneal endometriosis (SPE) is described as a small focus of T1 hyperintensity. Imaging has become a critical tool in the diagnosis, surveillance and surgical planning of endometriosis. This literature review is based mostly on studies from the last two decades and aims to provide a detailed overview of the imaging features of endometriosis as well as the advances and usefulness of different imaging modalities for this condition.

Prevalence of endometrioma and deep infiltrating endometriosis at transvaginal ultrasound examination of subfertile women undergoing assisted reproductive treatment

OBJECTIVE

To estimate the prevalence of endometrioma and deep infiltrating endometriosis (DIE), assessed by systematic transvaginal ultrasound examination, in women with subfertility accepted for their first assisted reproductive treatment and to describe the prevalence of endometriotic lesions in different anatomical locations of the pelvis.

DESIGN

Cross-sectional study.

SETTING

Reproductive Medicine Center, Department of Obstetrics and Gynecology, University hospital.

PATIENT(S)

A total of 1,191 women with subfertility aged 25-39 years accepted for their first assisted reproductive treatment between December 2018 and May 2021.

INTERVENTION(S)

All women underwent a systematic transvaginal ultrasound examination. The endometriotic lesions visible on ultrasound examination were described according to the International Deep Endometriosis Analysis group consensus opinion for systematic approach to assess endometriotic lesions.

MAIN OUTCOME MEASURE(S)

Prevalence of endometrioma and DIE in women with subfertility and prevalence of endometriotic lesions in various anatomical locations of the pelvis.

RESULT(S)

Endometriosis prevalence was 21.8%, with endometriotic lesions found in 260 of the 1,191 women. Overall, 125 (10.5%) women had endometrioma and 205 (17.2%) women had DIE. Of these 260 women, 197 (75.8% of women with endometriosis) did not have any previous knowledge about having endometriosis. The most common location for endometriotic lesions was the uterosacral ligaments, with lesions found in 151 (12.7%) of all women. The second most common location was the ovaries containing endometrioma, found in 125 (10.5%) women. Most women had 1 (n = 121, 10.2%) or 2 (n = 82, 6.9%) endometriotic lesions.

CONCLUSION(S)

The prevalence of endometrioma and DIE in women with subfertility, diagnosed by systematic transvaginal ultrasound examination, was 21.8%. Of these, three-fourth of women had no knowledge about the presence of disease.

Diagnostic accuracy of sliding sign for detecting pouch of Douglas obliteration and bowel involvement in women with suspected endometriosis: systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of the sliding sign on transvaginal ultrasound (TVS) in detecting pouch of Douglas obliteration and bowel involvement in patients with suspected endometriosis, using laparoscopy as the reference standard.

METHODS

A search for studies evaluating the role of the sliding sign in the assessment of pouch of Douglas obliteration and/or bowel involvement using laparoscopy as the reference standard published from January 2000 to October 2021 was performed in PubMed/MEDLINE, Web of Science, CINAHL, The Cochrane Library, ClinicalTrials.gov and SCOPUS databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to evaluate the quality of the studies. Analyses were performed using MIDAS and METANDI commands in STATA.

RESULTS

A total of 334 citations were identified. Eight studies were included in the analysis, resulting in 938 and 963 patients available for analysis of the diagnostic accuracy of the sliding sign for pouch of Douglas obliteration and bowel involvement, respectively. The mean prevalence of pouch of Douglas obliteration was 37% and the mean prevalence of bowel involvement was 23%. The pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the sliding sign on TVS for detecting pouch of Douglas obliteration were 88% (95% CI, 81-93%), 94% (95% CI, 91-96%), 15.3 (95% CI, 10.2-22.9), 0.12 (95% CI, 0.07-0.21) and 123 (95% CI, 62-244), respectively. The heterogeneity was moderate for sensitivity and low for specificity for detecting pouch of Douglas obliteration. The pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the sliding sign on TVS for detecting bowel involvement were 81% (95% CI, 64-91%), 95% (95% CI, 91-97%), 16.0 (95% CI, 9.0-28.6), 0.20 (95% CI, 0.10-0.40) and 81 (95% CI, 34-191), respectively. The heterogeneity for the meta-analysis of diagnostic accuracy for bowel involvement was high.

CONCLUSION

The sliding sign on TVS has good diagnostic performance for predicting pouch of Douglas obliteration and bowel involvement in women with suspected endometriosis. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Transvaginal ultrasound evaluation of the pelvis and symptoms after laparoscopic partial cystectomy for bladder endometriosis

Objective:

To evaluate transvaginal sonography (TVS) findings after laparoscopic partial cystectomy for bladder endometriosis and to correlate postsurgical ultrasound findings with symptoms.

Material and Methods:

A retrospective study including women who underwent laparoscopic partial cystectomy for bladder endometriosis. Within 12 months after surgery, TVS examination was conducted in all patients to evaluate the bladder morphology, and the presence of any postsurgical sonographic findings of the pelvis. Painful symptoms were assessed using a visual analogue scale.

Results:

A total of 40 women were included. At the follow-up visit, 25 patients were receiving medical treatment while 15 had declined post-surgical therapy and had tried to conceive. The presence of bladder deep-infiltrating endometriosis (DIE) was found in nine (22.5%), fibrotic thickening of the bladder wall was found in 15 (37.5%), and normal bladder morphology was observed in 16 (40%). There was a correlation between anterior adenomyosis and bladder DIE, and fibrotic thickening of the bladder. Patients with TVS signs of bladder DIE and anterior adenomyosis suffered more dysmenorrhea and dysuria than patients with normal bladder.

Conclusion:

Post-operative TVS can detect the alteration of pelvis and could explain the causes of the persistence of symptoms.

Diagnostic accuracy of transvaginal ultrasound for detection of endometriosis using International Deep Endometriosis Analysis (IDEA) approach: prospective international pilot study

OBJECTIVE

To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in predicting deep endometriosis (DE) following the International Deep Endometriosis Analysis (IDEA) consensus methodology.

METHODS

This was an international multicenter prospective diagnostic accuracy study involving eight centers across six countries (August 2018-November 2019). Consecutive participants with endometriosis suspected based on clinical symptoms or historical diagnosis of endometriosis were included. The index test was TVS performed preoperatively in accordance with the IDEA consensus statement. At each center, the index test was interpreted by a single sonologist. Reference standards were: (1) direct visualization of endometriosis at laparoscopy, as determined by a non-blinded surgeon with expertise in endometriosis surgery; and (2) histological assessment of biopsied/excised tissue. Surgery was performed within 12 months following the index TVS. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios (LR+ and LR-) of TVS in the diagnosis of DE were calculated.

RESULTS

Included in the study were 273 participants with complete clinical, TVS, laparoscopic and histological data. Of these, based on histology, 256 (93.8%) were confirmed to have endometriosis, including superficial endometriosis, and 190 (69.6%) were confirmed to have DE. Based on surgical visualization, 207/273 (75.8%) patients had DE. For DE overall, the diagnostic performance of TVS based on surgical visualization as the reference standard was as follows: accuracy, 86.1%; sensitivity, 88.4%; specificity, 78.8%; PPV, 92.9%; NPV, 68.4%; LR+, 4.17; LR-, 0.15, and the diagnostic performance of TVS based on histology as the reference standard was as follows: accuracy, 85.9%; sensitivity, 89.8%; specificity, 75.9%; PPV, 90.4%; NPV, 74.6%; LR+, 3.72; LR-, 0.13.

CONCLUSIONS

Using the IDEA consensus methodology provides strong diagnostic accuracy for TVS assessment of DE. We found a higher TVS detection rate of DE overall than that reported by the most recent meta-analysis on the topic (sensitivity, 79%), albeit with a lower specificity. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence of endometriosis and adenomyosis at transvaginal ultrasound examination in symptomatic women

INTRODUCTION

Prevalence of endometriosis is commonly reported based on surgery findings and varies widely depending on study population and indication for surgery. Symptoms such as dysmenorrhea, pelvic pain, dyspareunia, dysuria, and dyschezia can be associated with endometriosis and adenomyosis. Transvaginal ultrasound examination is proposed to be the first-line diagnostic method, nevertheless there are no published ultrasound-based studies reporting prevalence of endometriosis and adenomyosis in symptomatic women other than those scheduled for surgery. The aim of this study was to determine the prevalence of endometriosis and adenomyosis as assessed by transvaginal ultrasound in women with symptoms suggestive of endometriosis and adenomyosis.

MATERIAL AND METHODS

This is a retrospective cross-sectional study performed at a tertiary-care center including 373 symptomatic women who were systematically examined with transvaginal ultrasound by an experienced ultrasound examiner. Before ultrasound examination women filled in a questionnaire including self-assessment of the severity of their symptoms (dysmenorrhea, chronic pelvic pain, dyspareunia, dysuria, dyschezia) using a visual analog scale. Abnormal findings in the uterus, ovaries, bowel, urinary bladder, uterosacral ligaments, and rectovaginal septum were noted, and their size and location were described. Prevalence of endometriosis, adenomyosis, endometrioma, and deep endometriosis in different anatomical locations was reported.

RESULTS

Prevalence of ovarian endometrioma and/or deep endometriosis was 25% and of adenomyosis was 12%. Prevalence of endometrioma was 20% and of deep endometriosis was 9%, for each location being 8% in the bowel, 3% in the uterosacral ligaments, 3% in the rectovaginal septum and 0.5% in the urinary bladder.

CONCLUSIONS

In symptomatic women examined with transvaginal ultrasound by an experienced ultrasound examiner, ovarian endometrioma and/or deep endometriosis was found in one of four women and adenomyosis in one of nine women. Deep endometriosis was present in one of 11 women. Despite having symptoms, half of the women had no abnormal ultrasound findings.

Ovarian Immobility at Transvaginal Ultrasound: An Important Sonographic Marker for Prediction of Need for Pelvic Sidewall Surgery in Women With Suspected Endometriosis

OBJECTIVES

To determine whether ovarian fixation at transvaginal ultrasound (TVU) is a marker for a need for laparoscopic pelvic sidewall surgery (ie, ureterolysis or dissection of adhesions involving the pelvic sidewall). The relationship between ovarian immobility at TVU with respect to endometriosis staging using the revised American Fertility Society (r-AFS) classification was also evaluated.

METHODS

Retrospective diagnostic accuracy study was performed in a tertiary referral hospital and two private hospitals. Sixty-six women with pelvic pain underwent detailed TVU preoperatively followed by laparoscopic endometriosis surgery. TVU ovarian mobility findings (ie, mobile versus fixed ovary) were compared to surgical findings, the need for laparoscopic pelvic sidewall surgery and r-AFS score (I-IV).

RESULTS

Complete ultrasound and surgical data were available for 66 of 77 (86%) women. Twenty-six of 66 (40%) had isolated superficial peritoneal endometriosis, 15 of 66 (23%) had ovarian endometrioma (OE), 13 of 66 (20%) had pelvic deep endometriosis (DE). Twenty-seven of 66 (41%) had ovarian fixation at TVU. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of ovarian fixation at TVU for the prediction of need for laparoscopic pelvic sidewall surgery was 71%, 61%, 86%, 85%, and 62%, respectively (P = .0002). Ovarian fixation at TVU was significantly associated with the presence of ipsilateral OE, pouch of Douglas obliteration, pelvic DE nodules, and r-AFS stage III/IV (moderate/severe) endometriosis (all P-values <.05).

CONCLUSIONS

Ovarian fixation at TVU appears to be a marker for moderate/severe endometriosis and the need for laparoscopic pelvic sidewall surgery. This sign may be a valuable "red flag" for identifying women at increased risk of requiring an advanced laparoscopic surgeon, and in turn, improve surgical planning.

Difficulty in predicting intra‐abdominal adhesion before cesarean section: A case report

Severe adhesions between the bladder and uterus necessitated an atypical incision in the cesarean section of a woman with endometriosis. This could not be predicted with pre‐surgery MRI. No methods in the literature are able to predict adhesions with true certainty; it is therefore still difficult to diagnose intra‐abdominal adhesions.

Imaging of Endometriosis: The Role of Ultrasound and Magnetic Resonance

Endometriosis is a chronic gynecological disease characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus. It causes pelvic pain, dysmenorrhea, dyspareunia, or infertility. Diagnosis requires a combination of clinical history, non-invasive and invasive techniques. The aim of the present review was to evaluate the contribution of imaging techniques, mainly transvaginal sonography and magnetic resonance imaging to diagnose different locations and for the most appropriate treatment planning. Endometriosis requires a multidisciplinary teamwork to manage these patients clinically and surgically.

Preoperative sonographic prediction of intra-abdominal adhesions using sliding sign at repeat caesarean section at the University of Maiduguri Teaching Hospital, Nigeria: a prospective observational study

OBJECTIVE

To determine if the presence or absence of sonographic sliding sign preoperatively is a good predictor of the presence and type of intra-abdominal adhesions; and to determine the time taken to demonstrate this sign.

DESIGN

A prospective, observational, triple-blind study using tests of diagnostic accuracy.

SETTING

Single-centre tertiary health institution in north-east Nigeria.

PARTICIPANTS

67 women in the third trimester scheduled for repeat elective caesarean sections (CS) had transabdominal sonography to determine the absence or presence and degree of sliding sign. The time taken to make these decisions were noted. Surgeons blinded to the ultrasound findings graded adhesions intraoperatively and comparison between sonographic and intraoperative findings made. Women who were scheduled for emergency CS were excluded.

MAIN OUTCOME MEASURES

Accuracy of preoperative ultrasound to determine no/mild, moderate and severe adhesions. Secondary outcomes were interobserver correlations and time taken to determine sliding.

RESULTS

When classified as adhesion and no adhesion, the sliding sign demonstrated a sensitivity of 100.00% (CI₉₅ 85.18% to 100.00%), specificity of 100.00% (CI₉₅ 92.13% to 100.00%). In predicting presence of moderate intra-abdominal adhesions, a sensitivity of 65.0% (CI₉₅ 40.78% to 84.61%) and specificity of 82.98% (CI₉₅ 69.19% to 92.35%) was found. For predicting severe intra-abdominal adhesions, it had a sensitivity of 25.00% (CI₉₅ 0.63% to 80.59%) and specificity of 98.41 (CI₉₅ 91.47 to 99.96). Disease prevalence for mild, moderate and severe adhesions was 33.82% (CI₉₅ 22.79% to 46.32%), 29.85% (CI₉₅ 19.28% to 42.27%) and 5.97% (CI₉₅ 1.65% to 14.59%), respectively. Interobserver Cohen's kappa coefficient and PPA were 0.58 (CI₉₅ 0.39 to 0.76) and 58.82 (CI₉₅ 52.82 to 64.82), respectively. The mean duration to determine sliding sign was 7.56±2.86 s.

CONCLUSION

This study supports the role of transabdominal sliding sign in preoperative prediction of intra-abdominal adhesions in women with previous CS without significant increase in sonography duration. This information can encourage planning for CS by ensuring that surgeons of appropriate seniority are deployed to undertake anticipated complex operations.

Indirect and atypical imaging signals of endometriosis: A wide range of manifestations

Background

Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning.

Objective

To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI).

Methods

Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors.

Results

Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis.

MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants.

Conclusion

The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

Role of preoperative ultrasound mapping in the surgical management of deep infiltrating endometriosis: a prospective observational study

Background

Endometriosis is a challenging gynecological condition that has a profound influence on the quality of life of affected women. Transvaginal ultrasound is considered the first-line imaging method in preoperative assessment of the extent and severity of endometriosis. Accurate preoperative mapping can aid the surgeon in patient counselling, selection of the most appropriate surgical method that minimizes the operative and post-operative complications. The aim of our study is to evaluate the accuracy of transvaginal sonography (TVS) in precisely assessing the size, location and extent of deep infiltrating endometriosis (DIE) using a new modified endometriosis mapping proforma with histopathological confirmation. Our prospective observational study included 101 women with clinically suspected DIE who underwent TVS followed by laparoscopy from October 2018 to December 2020 with a maximum of 4 weeks interval. Precise mapping of DIE was done during TVS and laparoscopy. Results were correlated with histopathology findings.

Results

DIE was confirmed by histopathology in 88 patients. Sensitivity and specificity for individual DIE locations were rectovaginal septum 67.9% and 98.6%; vagina 52.2% and 98.7%; uterosacral ligaments 82.5% and 96.2%; torus 96.4% and 97.3%; parametrium 68.8% and 96.9%; rectum 100% and 98.8%; bladder 100% and 100%, ureters 63.4% and 99.0%; scar endometriosis 100% and 100%; pouch of Douglas obliteration 97.7% and 100%. No statistically significant difference was detected between ultrasound and histopathology size. Ultrasound tended to underestimate the lesion size; the underestimation was more pronounced for lesions > 3 cm. “Butterfly” and “tram-track” signs are two new sonographic signs related to posterior compartment DIE. No post-operative complications were recorded. There were no cases of DIE recurrence. Eleven out of 22 cases of infertility achieved pregnancy during 18 months follow-up.

Conclusion

TVS provides a thorough and accurate evaluation of the extent of endometriosis. An experienced radiologist can use E-PEP to provide an accurate demonstration of the location and extent of DIE which helps the surgeon select the most appropriate surgical approach ensuring radical treatment of the disease and minimizing short- and long-term complications.

Clinical Aspects of Adolescent Endometriosis

Early diagnosis and long-term management of endometriosis is important in adolescent girls considering their potential for future pregnancy and need for preventing disease progression. However, symptoms and clinical findings of adolescent endometriosis may differ from those of typical adult endometriosis, making diagnosis difficult. In adolescents, menstrual pain may present as acyclic and unresponsive to commonly used medication. Typical imaging findings in adult endometriosis, such as ovarian endometriotic cysts and fibrotic scars, are less common in adolescents. Peritoneal lesions, characteristic of early-stage endometriosis, are commonly found in this age group. It should be noted that endometriosis may also be found in adolescents before menarche, because of premenarcheal endometriosis or congenital uterine anomaly and outflow obstruction; the latter requiring surgical correction. Although surgery is reported to be effective for pain, postsurgical recurrence rate is high, and the effect of hormonal treatment is controversial. The optimal timing for surgical intervention also remains to be determined. Here, we aim to identify the unique characteristics of endometriosis in adolescents to achieve early diagnosis and optimal management for this group of patients.

Transvaginal Ultrasound Findings After Laparoscopic Rectosigmoid Segmental Resection for Deep Infiltrating Endometriosis

OBJECTIVES

To evaluate transvaginal ultrasound (TVUS) findings in patients who underwent segmental rectosigmoid resection for deep infiltrating endometriosis (DIE) and to correlate postsurgical ultrasound findings with symptoms.

METHODS

A retrospective study including 50 premenopausal women with bowel endometriosis who underwent segmental rectosigmoid resection was conducted. Within 12 months after surgery, a TVUS examination was conducted in all patients to evaluate the presence of postsurgical endometriosis locations and symptoms, including dysmenorrhea, dyspareunia, dysuria, dyschezia, and chronic pelvic pain. Pelvic pain was assessed in all women by a visual analog scale.

RESULTS

At the follow-up 32 of 50 patients were receiving medical treatment, whereas 18 women declined postsurgical medical therapy and tried to conceive. A high percentage of adhesions (90%) was found. A negative sliding sign (a simple diagnostic sign that can be performed during a TVUS examination, consisting of gentle pressure applied by both the vaginal transducer and the examiner's hand on the abdomen; if the uterus does not glide freely along with the rectum and posterior fornix, the sign is considered negative, and adhesions can be suspected) was found in 29 (58%) women and was associated with bowel symptoms. Recurrence of posterior DIE was found in 9 cases (18%) and endometriomas in 8 cases (16%). Adenomyosis was observed in 80% of women and was present in all symptomatic patients.

CONCLUSIONS

After rectosigmoid segmental resection patients with DIE may continue to be symptomatic, and postoperative TVUS may reveal foci of disease or pelvic adhesions. Moreover, adenomyosis could be linked to symptoms experienced during follow up. Women should be aware that painful symptoms and alterations of pelvic organs could still be present after surgery and be detectable by TVUS.

Impact of Uterine Sliding Sign in Routine United States Ultrasound Practice

OBJECTIVES

The study aim was to evaluate the diagnostic performance of the uterine sliding sign in predicting deeply infiltrating endometriosis in the setting of non-physician sonographers performing but not interpreting the maneuver. The impact of uterine sliding sign has not been previously demonstrated in this practice setting.

METHODS

Physicians' remote interpretations of transvaginal ultrasound examinations in 2016, before uterine sliding sign, were compared to examinations in 2019 after addition of uterine sliding sign to determine the diagnostic rates. Surgical and histopathological results were reviewed to determine sensitivity and specificity of the respective exam techniques.

RESULTS

Two hundred eighty-five transvaginal ultrasounds were performed in 2016 and 390 sliding sign ultrasounds in 2019. The number of deeply infiltrating endometriosis cases identified increased significantly from 2% to 6% during the study period (chi-square, Fisher's exact test p = .012). The sensitivity and specificity of routine pelvic sonography for detecting deeply infiltrating endometriosis improved from 36%/94% to 68%/98%.

CONCLUSIONS

Uterine sliding sign videos should be included in the standard sonographic protocol for patients presenting with chronic pelvic pain, endometriosis history, or sonographic evidence of endometriosis in the setting of physicians interpreting sonographic images obtained by non-physicians.

Vaginal ultrasound-guided Pouch of Douglas robotic entry in a live ovine model and human female cadaveric specimens

We aimed to determine whether intraoperative ultrasound is a feasible tool for visualization of the pouch of Douglas (POD) to facilitate a safe vaginal entry for direct robotic vaginal trocar insertion for pelvic floor surgery. Endovaginal ultrasound-guided needle insertion of a trocar into the POD was performed in six fresh frozen female cadavers and a live sheep animal model. Using an endovaginal probe the POD was identified as a fluid-filled space clear of bowel or adhesions, then a Veress needle was also used to confirm POD localization. Access to the POD was achieved using a robotic trocar designed for this purpose. The animal study was approved by the Ethics Committee of Asaf-Harofe hospital. Direct visualization during laparoscopy in cadavers and open cadaveric dissections confirmed safe POD entry and accurate trocar placement. This method was found feasible in the development of a safe vaginal entry in both the animal and cadaveric model, possibly negating the need for laparoscopic umbilical observation.

Ureter Visualization With Transvaginal Ultrasound: A Learning Curve Study

OBJECTIVES

To evaluate the learning curve of gynecologic surgical fellows (ie, in training) to properly identify the ureters in real time while simultaneously performing and interpreting transvaginal ultrasound (TVUS) examinations.

METHODS

We performed a prospective study, which took place at 2 centers in Sydney, Australia, from December 2017 to December 2018. Three fellows (F1-F3), of varying prestudy ultrasound (US) experience, were recruited to participate. One hundred fifty predetermined examinations were planned. A TVUS examination was performed by the study reference standard (an expert in gynecologic US). Subsequently, the fellows performed a focused component to identify bilateral ureters, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's evaluations were complete. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used.

RESULTS

A total of 150 examinations were performed on 145 patients. One patient had a single ureter, and 1 patient had US evidence of hydroureter. The cumulative summation test for the learning curve for bilateral ureter identification showed that F1 did not reach competency by 50 TVUS examinations, whereas F2 and F3 required 41 and 31 TVUS examinations to reach competency, respectively.

CONCLUSIONS

Contrary to other studies on the topic, this study suggests that although it is feasible for surgical fellows to learn TVUS identification of bilateral ureters, not all fellows can reach competency during a program based on a predefined number of scans. We advocate for an individualized, competency-based medical education model in learning US for identifying the ureters.

One-Size-Fits-All Approach Does Not Work for Gynecology Trainees Learning Endometriosis Ultrasound Skills

OBJECTIVES

To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations.

METHODS

We performed a prospective study between December 2017 and December 2018. Three fellows (F1-F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used.

RESULTS

A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%-94%). The overall accuracy of POD state classification was 93% (range, 90%-96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans.

CONCLUSIONS

Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.

Prevalence of negative sliding sign representing pouch of Douglas obliteration during pelvic transvaginal ultrasound for any indication

OBJECTIVES

Pouch of Douglas (POD) obliteration can be predicted with a high degree of certainty and reproducibility using the dynamic transvaginal ultrasound (TVS) sliding-sign technique. So far, studies on POD obliteration prediction have focused on tertiary-care populations with high prevalence of endometriosis; however, POD obliteration may exist in individuals with asymptomatic endometriosis or other conditions. Our primary aim was to determine the prevalence of a negative sliding sign, representing POD obliteration, in a cohort of patients undergoing TVS for any gynecological indication.

METHODS

This was a prospective observational study of consecutive women with an indication for gynecological TVS, conducted at a high-volume ultrasound practice between July and August 2018. Clinical and surgical history, indication for TVS and TVS findings were documented. The prevalence of TVS-confirmed POD obliteration, determined by interpretation of the sliding sign, was calculated for the entire cohort and for the subgroups of women with and without risk factors for endometriosis. High risk for endometriosis was defined as having (1) a TVS referral for endometriosis-like pelvic pain or endometriosis specifically and/or (2) clinical symptoms or signs suggestive of endometriosis. Low risk was defined as the absence of these characteristics.

RESULTS

During the study period, 1043 consecutive women underwent TVS. After excluding those who underwent transabdominal ultrasound, had a history of hysterectomy or with missing data, 909 women were analyzed. The prevalence of a negative sliding sign in the entire cohort was 47/909 (5.2%). A negative sliding sign was observed in 22/639 (3.4%) women with a low risk for endometriosis and 25/243 (10.3%) of those with a high risk for endometriosis (difference in proportions, 6.9% (95% CI 2.8-10.9%); P < 0.001).

CONCLUSIONS

We have demonstrated an overall prevalence of a negative sliding sign, suggesting POD obliteration, of 5.2% (or 1/20) in women seeking TVS for a gynecological indication. The prevalence of negative sliding sign in low-risk women is not negligible (3.4% or 1/29 women). These women are most likely to have asymptomatic endometriosis or another important etiology of POD obliteration. The prevalence of a negative sliding sign is approximately three-times higher in women with signs and/or symptoms of endometriosis (10.3% vs 3.4%). Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Adolescence and endometriosis: symptoms, ultrasound signs and early diagnosis

OBJECTIVE

To evaluate the ultrasonographic presence of different forms of endometriosis and the associated clinical symptoms in adolescent women.

DESIGN

Retrospective observational study.

SETTING

University hospital.

PATIENT(S)

Two hundred and seventy women aged 12-20 years referred to the gynecologic ultrasound unit from January 2014 to June 2019.

INTERVENTION(S)

Two-dimensional, three-dimensional, and power Doppler ultrasound (US) pelvic examination (transvaginal or transrectal in pre-sexually active adolescents) were performed in all included adolescents. Medical history was collected for each patient before the scan.

MAIN OUTCOME MEASURE(S)

All possible locations of endometriosis evaluated and recorded using a dedicated ultrasound mapping sheet and severity of painful symptoms evaluated through a visual analogue scale (VAS).

RESULT(S)

Dysmenorrhea was detected in 147 (54.4%) of 270 patients and heavy menstrual bleeding in 76 (28.1%) of 270. At least one ultrasound feature of endometriosis was identified in 36 (13.3%) of 270 cases. Ovarian endometriomas were found in 22 (11%) patients, adenomyosis in 16 (5.2%), and deep infiltrating endometriosis (DIE) in 10 (3.7%). Ultrasound signs of endometriosis were found in 21% of adolescents who reported dysmenorrhea and 33% with dyspareunia. The presence of DIE at ultrasound was associated with bowel symptoms in 33% of patients and associated with dyspareunia in 25% of patients.

CONCLUSION(S)

The detection rate of pelvic endometriotic lesions at ultrasound was 13%. The rates of dysmenorrhea, dyspareunia and heavy menstrual bleeding in adolescents with endometriosis ultrasound signs were statistically significantly higher compared with those without. In patients with dysmenorrhea, the detection rate of pelvic endometriosis at ultrasound increased to 20%. Professionals involved with teens should be aware of the clinical presentation of endometriosis to reduce the delay between the onset of symptoms and the diagnosis, referring these young women to dedicated centers.

Early Learning Curve in the Assessment of Deep Pelvic Endometriosis for Ultrasound and Magnetic Resonance Imaging

Purpose

We aimed to compare the learning curves of an ultrasound trainee (obstetrics and gynecology resident) and a radiology trainee when assessing pelvic endometriosis.

Methods

Consecutive patients with suspected endometriosis were prospectively enrolled in a tertiary center. They underwent an ultrasound and magnetic resonance imaging preoperatively, which was reported according to the International Deep Endometriosis Analysis (IDEA) group consensus. Trainees reported on deep endometriosis (DE), endometriomas, frozen pelvis, and adenomyosis. Using the Kappa agreement, their findings were compared against laparoscopy/histology and expert findings. The learning curve was considered positive when performance improved over time and indeterminate in all other cases.

Results

Reports from thirty-five women were divided chronologically into 3 equal blocks to assess the learning curve. For ultrasound, trainee versus expert showed a positive learning curve in overall pelvic DE assessment. There was an excellent agreement for adenomyosis (Kappa = 1.00, p = 0.09), frozen pelvis (Kappa = 0.90, p = 0.01), bowel (Kappa = 1.00, p = 0.01), and bladder DE assessment (Kappa = 1.00, p = 0.01). Endometrioma and uterosacral ligament assessment showed an indeterminate curve. For radiology, trainee versus expert showed a positive curve when detecting adenomyosis (Kappa = 0.42, p = 0.09) and bladder DE (Kappa = 1.00, p = 0.01). The assessment of endometriomas, frozen pelvis, overall pelvic DE, bowel, and uterosacral ligament DE showed indeterminate curve. Agreement between trainees and laparoscopy/histology showed a positive curve for bladder (both) and frozen pelvis (ultrasound only).

Conclusion

A positive learning curve can be seen in some areas of pelvic endometriosis mapping after as little as 35 cases, but a bigger caseload is required to demonstrate the curve in full. The ultrasound trainee had positive learning curves in more anatomical locations (bladder, adenomyosis, overall bowel DE, frozen pelvis) than the radiology trainee (bladder, adenomyosis), which could be down to individual factors, differences in training, or the imaging method itself.

SonoPODography: A new diagnostic technique for visualizing superficial endometriosis

OBJECTIVE

To perform a pilot diagnostic accuracy study of a novel transvaginal ultrasonography procedure called saline-infusion sonoPODography to predict superficial endometriosis in patients with suspected endometriosis.

STUDY DESIGN

A prospective single-center diagnostic accuracy study was performed from September 2019-November 2019. The index test sonoPODography was performed and the results were documented in a standardized fashion. SonoPODography was performed by installing saline into the pouch of Douglas (POD) via an intrauterine balloon catheter to create an acoustic window between the ultrasound probe and surrounding structures. The pelvis was then assessed for the presence or absence of superficial endometriosis using pre-defined features. Direct visualization at laparoscopy and histological assessment of excised endometriosis confirmed the outcome. The diagnostic performance of sonoPODography was evaluated.

RESULTS

42 consecutive participants underwent sonoPODography. Superficial endometriosis was identified by sonoPODography in 24/42 (57.1 %) and in 37/42 (88.1 %) participants by direct visualization at laparoscopy. The overall diagnostic performance of sonoPODography was: accuracy 69.1 %, sensitivity 64.9 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 27.8 %. Amongst those without deep endometriosis/endometriomas/pouch of Douglas obliteration, the diagnostic performance was: accuracy 80.0 %, sensitivity 77.7 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 33.3 %. The pouch of Douglas peritoneum was the most common site of superficial endometriosis.

CONCLUSIONS

SonoPODography is a novel ultrasound-based procedure that permits the direct visualization of superficial with respectable diagnostic accuracy. The findings of this pilot study are promising and justify the initiation of a larger outpatient study. SonoPODography may establish new avenues for the non-invasive diagnosis and investigation of endometriosis.

Current Status of Transvaginal Ultrasound Accuracy in the Diagnosis of Deep Infiltrating Endometriosis Before Surgery: A Systematic Review of the Literature

Endometriosis is a common gynecologic condition affecting as many as 1 per 10 women. Transvaginal ultrasound (TVUS) has become a frontline tool in the diagnosis of deep infiltrating endometriosis (DIE) before surgery. The primary aim of this review was to determine the accuracy of TVUS for DIE. The secondary aim was to determine accuracy specifically when a sonographer performed the TVUS examination. A systematic review was performed, searching literature by following a population, intervention, comparator, and outcome outline. MEDLINE, Embase, Emcare, and Google Scholar were searched in July 2018 and in November 2019. Including "sonographer" in the search terms yielded no results, so our terms were expanded. Two hundred and four articles were returned from the searches, and 35 were ultimately included in the final review. Analysis of the returned articles revealed the TVUS is a valuable diagnostic tool for DIE before surgery. Sensitivities ranged from 78.5% to 85.3%, specificities from 46.1% to 92.5%, and accuracies from 75.7% to 97%. Most authors reported site-specific sensitivities and specificities, which varied greatly between locations. Site-specific sensitivities ranged from 10% to 88.9% (uterosacral ligaments), 20% to 100% (bladder), 33.3% to 98.1% (rectosigmoid colon), and 31% to 98.7% (pouch of Douglas). Site-specific specificities ranged from 75% to 99.6% (uterosacral ligaments), 96.4% to 100% (bladder), 86% to 100% (rectosigmoid colon), and 90% to 100% (pouch of Douglas). Transvaginal ultrasound is an accurate tool in the diagnosis of DIE; however, limited data exist as to whether this technique is accurate when performed by sonographers. More evidence surrounding the reliability between operators is also needed.

Sonographer-acquired ultrasound protocol for deep endometriosis

Endovaginal sonographic imaging has been shown to reliably identify pelvic endometriosis, but most United States imaging practices do not adequately assess locations and features of endometriosis beyond ovarian endometrioma. In this article, we propose a protocol for sonographer-acquired images and maneuvers to be interpreted subsequently by sonologists (radiologists or gynecologists). The purpose is to improve the sensitivity of endovaginal sonography for the detection of endometriosis in imaging practices that involve the non-physician sonographer as part of their workflow.

Imaging of gastrointestinal endometriosis: what the radiologist should know

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

Negative Sliding Sign during Dynamic Ultrasonography Predicts Low Endometriosis Fertility Index at Laparoscopy

STUDY OBJECTIVE

Endometriosis fertility index (EFI) is a robust tool to predict the pregnancy rate in patients with endometriosis who are attempting non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Newly established imaging techniques such as sliding sign, which is used to diagnose pouch of Douglas obliteration, could provide a promising alternative. The objective of this study was to investigate the practicality of using ultrasound data to predict a low EFI (score ≤6).

DESIGN

Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort, clinicaltrials.gov #NCT02911090). Analyzed data were captured from December 2013 to June 2017.

SETTING

Tertiary referral center at British Columbia Women's Hospital.

PATIENTS

We analyzed data for 2583 participants from the Endometriosis Pelvic Pain Interdisciplinary Cohort. In this cross-sectional study, we included 86 women aged <40 years.

INTERVENTIONS

Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Logistic regression was used to obtain receiver operating characteristic area under the curve (AUC) for the prediction models. Significance was p <.05. Patients with a negative sliding sign were older and had severe endometriosis and longer duration of infertility. Patients with a negative sliding sign had significantly lower total EFI scores and lower surgical factors scores than patients with a positive sliding sign. Logistic regression showed that a negative sliding sign and EFI historic factors score can predict an EFI score ≤6 (sensitivity = 87.9%, specificity = 81.1%, AUC = 0.93 [95% confidence interval, 0.88-0.98]). Adding the diagnosis of endometrioma to the previous prediction model resulted in AUC = 0.95 (95% confidence interval, 0.90-0.995), sensitivity = 84.8%, and specificity = 92.5%.

CONCLUSION

The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historic factors and the diagnosis of endometrioma to predict an EFI score ≤6 for patients who are not scheduled for immediate surgery.

Transvaginal US of Endometriosis: Looking Beyond the Endometrioma with a Dedicated Protocol

Transvaginal sonography (TVS) is a valuable primary imaging tool for the initial evaluation and management of endometriosis, a complex multifocal disease process with a varied spectrum of clinical and morphologic features that can substantially affect quality of life. The high accuracy of TVS for the detailed mapping of disease extent, an essential process for guiding treatment strategies, is well documented. The dynamic nature of US provides added value, revealing information that is not easily addressed with other imaging modalities. As recognized by the International Deep Endometriosis Analysis Consensus Group, a dedicated standardized protocol that is used by experienced and knowledgeable operators is necessary for a complete evaluation. The four components of a dedicated TVS protocol for evaluation of pelvic endometriosis are (a) evaluation of the uterus and adnexa, (b) dedicated search for deep infiltrating endometriosis, (c) assessment of the sliding sign, and (d) detection of sonographic soft markers. These components are described, and the multiple locations and US findings of endometriosis within the pelvis are reviewed, with emphasis on the unique features of US as an extension of the physical examination. In addition to enabling evaluation of the static findings of adenomyosis, endometrioma, hydrosalpinx, hematosalpinx, and hypoechoic nodules of deep infiltrating endometriosis, dynamic TVS enables assessment of pouch of Douglas obliteration, organ mobility, and site-specific tenderness, as well as tenderness-guided imaging. The benefits of implementing a dedicated TVS protocol in terms of improved patient care are also discussed. Online supplemental material is available for this article. ^©RSNA, 2019.

Diagnosing Deep Endometriosis Using Transvaginal Elastosonography

Transvaginal ultrasound (TVUS) and MRI are currently two mainstream imaging techniques used to diagnose deep endometriosis (DE) with comparable accuracy, but there is still ample room for improvement. As endometriotic lesions progress to fibrosis concomitant with the increase in tissue stiffness, transvaginal elastosonography (TVESG) is well-suited for diagnosing DE. To test the hypothesis that lesional stiffness as measured by TVESG correlates with the extent of lesional fibrosis, the markers of progression, hormonal receptor expression, and vascularity, we recruited 30 patients suspected to have DE who went through pelvic examination, TVUS and/or MRI, and TVESG and were ultimately diagnosed by histology. Their lesional tissue samples were subjected to immunohistochemistry analysis of markers for epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), estrogen and progesterone receptors (ERβ and PR), microvessel density (MVD), and vascularity, as well as quantification of lesional fibrosis. We found that pelvic examination, TVUS, and MRI detected 83.3%, 66.7%, and 83.3% of all DE cases, respectively, while TVESG detected them all. The lesions missed by pelvic exam, TVUS and MRI were significantly smaller than those detected but nonetheless had higher lesional stiffness. Lesional stiffness correlated closely and positively with the extent of lesional fibrosis, negatively with the markers of EMT, MVD, vascularity, and PR expression, but positively with the marker for FMT and ERβ. Thus, through the additional use of information on differential stiffness between DE lesions and their surrounding tissues, TVESG improves diagnostic accuracy, provides a ballpark estimate on the developmental stage of the lesions, and may help clinicians choose the best treatment modality.

Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis

OBJECTIVES

The aim of this study was to evaluate the use of ultrasound (US) soft markers as a first-line imaging tool to raise suspicion of rectosigmoid (RS) involvement in women suspected of having deep endometriosis.

METHODS

We included in this prospective observational study all patients with clinical suspicion of deep endometriosis who underwent diagnostic transvaginal US evaluation at our unit from January 2016 to February 2017. Several US soft markers were evaluated for prediction of RS involvement (presence of US signs of uterine adenomyosis, presence of an endometrioma, adhesion of the ovary to the uterus (reduced ovarian mobility), presence of 'kissing ovaries' (KO) and absence of the 'sliding sign'), using as the gold standard expert US examination for the presence of RS endometriosis.

RESULTS

Included were 333 patients with clinical suspicion of deep endometriosis. Of these, 106 had an US diagnosis of RS endometriosis by an expert. The only significant variables found in the prediction model were absence of the sliding sign (odds ratio (OR), 13.95; 95% CI, 7.7-25.3), presence of KO (OR, 22.5; 95% CI, 4.1-124.0) and the interaction between these two variables (OR, 0.03; 95% CI, 0.004-0.28). Regarding their interaction, RS endometriosis was present when KO was absent and the sliding sign was present in 10% (19/190) of cases, when both KO and the sliding sign were present in 71.4% (5/7) of cases, when both KO and the sliding sign were absent in 60.8% (76/125) of cases and when KO was present and the sliding sign was absent in 54.5% (6/11) of cases. Thus, when the sliding sign was absent and/or KO was present, transvaginal US showed a specificity of 75% (95% CI, 69-80%) and a sensitivity of 82% (95% CI, 73-88%).

CONCLUSIONS

US findings of absence of the sliding sign and/or presence of KO in patients with clinical suspicion of endometriosis should raise suspicion of RS involvement and indicate referral for expert US examination, with a low rate of false-negative diagnosis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Accuracy and clinical value of an adhesion scoring system: A preoperative diagnostic method using transvaginal ultrasonography for endometriotic adhesion

AIM

To investigate the accuracy and clinical value of an adhesion scoring system using transvaginal ultrasonography for endometriotic adhesion.

METHODS

In this prospective observational study, we included 131 patients with endometriosis who underwent surgery. Before surgery, transvaginal ultrasonography and adhesion mapping were performed to determine the presence or absence of adhesions at 10 sites of the pelvis. Mapping accuracy was determined by comparing the mapping findings with the surgical findings. To determine the severity of pelvic adhesions, we developed an adhesion score (0-10). With the adhesion score, we assessed the effect of surgical adhesiolysis and evaluated the relationship between postoperative adhesions and infertility.

RESULTS

Of the 10 sites assessed for adhesions, the most frequent site of adhesions was the site between the left ovary and the uterus (70.5%). The overall sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and accuracy of adhesion mapping were 80.4%, 86.1%, 78.8%, 87.2%, 5.79, 0.23 and 83.9%, respectively. The adhesion score in this system was significantly correlated with the adhesion-related score in the revised American Society for Reproductive Medicine classification (R² = 0.734). Surgical adhesiolysis yielded only about 30% improvement postoperatively. The adhesion score 1 month after surgery in the non-in vitro fertilization (IVF) pregnancy group was significantly lower than that in the IVF pregnancy group (3.45 vs 5.21; P = 0.02).

CONCLUSION

Our adhesion scoring system allowed an accurate prediction of the pelvic adhesion status and may potentially be an indicator of postoperative adhesions and infertility.

Predicting Pouch of Douglas Obliteration Using Ultrasound and Laparoscopic Video Sets: An Interobserver and Diagnostic Accuracy Study

OBJECTIVES

To investigate the diagnostic accuracy and interobserver agreement among sonologists when assessing offline ultrasound (US) video sets of the "sliding sign" and among gynecologic surgeons when assessing corresponding laparoscopic video sets to predict pouch of Douglas (POD) obliteration and to compare the performance of the groups.

METHODS

A diagnostic and reproducibility study was conducted, including 15 observers in 4 groups: (1) senior sonologists, (2) junior sonologists, (3) general gynecologists, and (4) advanced laparoscopists. The sonologists viewed 25 offline preoperative US video sets of the sliding sign, and the surgeons viewed the corresponding intraoperative laparoscopic videos of the same patients. Each observer was asked to classify POD obliteration in the video sets and was compared to the reference standard POD state determined at real-time laparoscopy by a single investigator (G.C.). The interobserver correlation and diagnostic accuracy were evaluated among the 15 observers and 4 groups. The Cohen κ coefficient and Fleiss κ coefficient were used for the analysis.

RESULTS

The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for senior sonologists were 93.3%, 100%, 89.6%, 84.4%, and 100%, respectively; for junior sonologists, 70.0%, 88.9%, 59.4%, 55.2%, and 90.5%; for general gynecologists, 75.2%, 88.1%, 78.1%, 69.8%, and 91.9%; and for advanced laparoscopists, 82.4%, 91.9%, 90.8%, 82.9%, and 95.8%. The overall agreement between senior sonologists was almost perfect (Fleiss κ = 0.876); for junior sonologists and general gynecologists, it was moderate (Fleiss κ = 0.589 and 0.528); and for advanced laparoscopists, it was substantial (Fleiss κ = 0.652).

CONCLUSIONS

Interobserver agreement was superior among senior sonologists. Prediction of POD obliteration using offline US videos by senior sonologists is comparable to offline assessments of laparoscopic videos by advanced laparoscopists for prediction of POD obliteration.

A Novel Ultrasound Technique Called Saline Infusion SonoPODography to Visualize and Understand the Pouch of Douglas and Posterior Compartment Contents: A Feasibility Study

Women with infertility are often investigated with saline-infusion sonohysterography and hysterosalpingo-contrast-sonography. The high prevalence of endometriosis in this population also warrants an evaluation with transvaginal ultrasound for deep endometriosis. To minimize investigations, we prospectively evaluated the feasibility of a novel combined ultrasound technique called saline-infusion sonoPODography. In most patients, the fluid infused to assess the cavity and tubal patency spilled through patent tubes and filled the pouch of Douglas, yielding a "standoff" view of posterior compartment structures, including uterosacral ligaments, rectovaginal septum, and the pouch of Douglas. We believe this improved our ability to evaluate this space.

Ultrasound Imaging in Endometriosis

Ultrasound examination is an indisputable imaging method in the diagnosis of endometriosis, as the first step in the detection, as the fundamental tool in planning the management, and as the best diagnostic instrument during surveillance of affected women. The aim of this article is to provide an update on the role of ultrasound in the detection, in the planning of medical and surgical treatment, and in the surveillance of patients with endometriosis.

Hemoperitoneum as a precursor of deep pelvic endometriosis: prospective cohort study

OBJECTIVE

To determine whether significant hemoperitoneum could be a precursor of deep pelvic endometriosis in non-pregnant premenopausal women presenting with severe acute lower abdominal pain.

METHODS

This was a prospective observational cohort study carried out at a dedicated gynecological diagnostic unit over a period of 18 months. We included consecutive non-pregnant, premenopausal women who attended with severe acute lower abdominal pain and underwent a pelvic ultrasound examination. Women were triaged for surgical or conservative management depending on the cause of pain and severity of their symptoms. Those who were selected for conservative management were invited for follow-up ultrasound scans. The main outcome measure was evidence of newly developed deep endometriosis at follow-up examination.

RESULTS

Of 118 non-pregnant women who attended our unit with severe acute lower abdominal pain, 20 underwent emergency surgery and 17 had a history of endometriosis, or evidence of endometriosis on the initial scan, and were excluded from the study. Therefore, conservative management was employed in 81 women, eight of whom had evidence of significant hemoperitoneum at presentation. A total of 35 women attended for all follow-up ultrasound scans. At the completion of follow-up, four of six (67% (95% CI, 22-96%)) women who presented initially with significant intra-abdominal bleeding had developed new evidence of deep endometriosis, compared with one of 29 (3% (95% CI, 0-18%)) of those without hemoperitoneum (relative risk, 19.3 (95% CI, 3-144); P < 0.001).

CONCLUSION

In some women, the presence of significant hemoperitoneum that is managed conservatively precedes the development of deep endometriosis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

A pictorial guide to the ultrasound identification and assessment of uterosacral ligaments in women with potential endometriosis

We believe the uterosacral ligaments (USLs) are an essential key to resolving the dilemma of diagnosing endometriosis non-invasively. This editorial will utilise laparoscopic and ultrasonographic figures and videos, along with written descriptive techniques, to educate clinicians, sonographers, sonologists and radiologists on normal and abnormal USLs to improve knowledge and skill in scanning patients with possible endometriosis.