Diagnostic accuracy of transvaginal sonography for detecting parametrial involvement in women with deep endometriosis: systematic review and meta-analysis

"From the tip to the deep of the iceberg": Parametrial involvement in endometriosis

Deep endometriosis (DE) can be localized in the parametrium, a complex bilateral anatomical structure, sometimes necessitating intricate surgical intervention due to the potential involvement of autonomic nerves, uterine artery, and ureter. If endometriotic ovarian cysts have been considered metaphorically representative of "the tip of the iceberg" concerning concealed DE lesions, it is reasonable to assert that parametrial lesions should be construed as the most profound region of this iceberg. Also, based on a subdual clinical presentation, a comprehensive diagnostic parametrial evaluation becomes imperative to strategize optimal management for patients with suspected DE. Recently, the ULTRAPARAMETRENDO studies aimed to evaluate the role of transvaginal ultrasound for parametrial endometriosis, showing distinctive features, such as a mild hypoechoic appearance, starry morphology, irregular margins, and limited vascularization. The impact of medical therapy on parametrial lesions has not been described in the current literature, primarily due to the lack of adequate detection at imaging. The extension of DE into the parametrium poses significant challenges during the surgical approach, thereby increasing the risk of intra- and postoperative complications, mainly if performed by centers with low expertise and following multiple surgical procedures where parametrial involvement has gone unrecognized. Over time, the principles of nerve-sparing surgery have been incorporated into the surgical DE treatment to minimize iatrogenic damage and potentially reduce the risk of functional complications.

Comparison of clinical and ultrasound examinations in assessing the parametria in patients with deep infiltrating endometriosis: a multicentre prospective study

RESEARCH QUESTION

How do clinical rectovaginal examination and transvaginal ultrasound examination perform in the diagnosis of parametrial infiltration in patients with endometriosis?

DESIGN

This was a multicentre prospective observational study. Patients with suspected deep endometriosis at clinical examination and/or at ultrasound evaluation and scheduled for surgery were included. Following multicentre multidisciplinary meetings, consensus was obtained on terms and methodology to define the parametrium at pelvic anatomy, ultrasound and surgery. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios were calculated for clinical and ultrasound examinations with respect to surgery.

RESULTS

In total, 195 women were selected for the present study and 164 were included in the analysis. Ultrasound examination had good to high specificity (>80%) for all parameters, except the left lateral parametrium (78.8%). The sensitivity of ultrasound examination was good to high for fixity of the right and left ovaries, uterosacral ligaments, retrocervix and rectovaginal space; and low for the anterior and lateral parametria, vagina, bladder and bowel. Clinical examination had good to high specificity for fixity of the left ovary, anterior parametrium, right uterosacral ligament, retrocervix and vagina; and low specificity for fixity of the right ovary, lateral parametrium, left uterosacral ligament and rectovaginal space. The sensitivity of clinical examination was good for the uterosacral ligaments and rectovaginal space, and low for the remaining parameters.

CONCLUSION

Ultrasound examination provided good specificity for all the parameters, but sensitivity was low for the anterior and lateral parametria. Clinical examination provided good specificity for the anterior and posterior parametria, but sensitivity was low for the anterior and lateral parametria. Further prospective studies are needed to validate this methodology and confirm the results.

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study

OBJECTIVE

The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria.

DESIGN

A diagnostic accuracy study was employed based on a prospective observational design.

PARTICIPANTS

All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered.

SETTING

The study was conducted at endometriosis referral hospitals.

METHODS

We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard.

RESULTS

In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70-96.92%, 95% CI) for the right side and 87.91% (79.40-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90-98.84%, 95% CI) and 96.22% (94.04-97.74%, 95% CI), respectively.

LIMITATIONS

The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives.

CONCLUSIONS

TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Transvaginal sonography and surgical findings in the diagnosis of endometriosis individuals: A cross-sectional study

BACKGROUND

Endometriosis is a challenging gynecological disease and a debilitating condition that profoundly affects the individual's quality of life. Besides pathological confirmation, diagnostic laparoscopy has been internationally accepted as the standard method to identify the accurate mapping of endometriosis. Transvaginal sonography (TVS) is the first non-invasive imaging modality to estimate the severity of endometriosis.

OBJECTIVE

This study aimed to evaluate the accuracy of TVS in affected women compared with surgical findings.

MATERIALS AND METHODS

This retrospective cross-sectional study surveyed 170 women with deep infiltrating endometriosis (DIE) referred to the endometriosis part of the Avicenna Infertility Center, Tehran, Iran and they underwent TVS followed by laparoscopy. Recorded data of individuals under study in the medical database system were reviewed. Finally, the agreement rate was calculated for ultrasound reports and intraoperative (IO) findings regarding ovarian endometrium, ovarian adhesion, involvement of cul-de-sac, rectovaginal septum, and bowel and ureter.

RESULTS

170 women with DIE entered the study. The agreement of TVS and IO findings were 86.76% for left ovarian endometriosis and 70.86% for right ovarian endometriosis, 93.90% for left ovarian adhesion, and 88.90% for right ovarian adhesion, 88.90% for a cul-de-sac, and 84.82% for bowel nodules. The findings, based on a laparoscopic assessment of the pelvic floor, were completely compatible with ultrasound reports (100%).

CONCLUSION

TVS allows a preoperative evaluation in planning the surgical policy associated. TVS is beneficial for dedicated mapping of DIE; thus, an expert radiologist can aid the surgeon in preoperative evaluation and IO management.

The Expanding Role of Sonography in the Clinical Practice of Modern Obstetrics and Gynecology: A Clinical Perspective

A list of gynecologic diagnoses is provided, which shows the use of sonography in significantly assisting the practice of modern clinical gynecology. The clinical value of this technology to assist in formulating diagnoses for the presenting patients is discussed. Sonography has become a necessary tool for today’s practice of gynecology, and women’s health, in general.

Current Updates on the Role of Microbiome in Endometriosis: A Narrative Review

Endometriosis affects approximately 6 to 10% of reproductive-age women globally. Despite much effort invested, the pathogenesis that promotes the development, as well as the progression of this chronic inflammatory disease, is poorly understood. The imbalance in the microbiome or dysbiosis has been implicated in a variety of human diseases, especially the gut microbiome. In the case of endometriosis, emerging evidence suggests that there may be urogenital-gastrointestinal crosstalk that leads to the development of endometriosis. Researchers may now exploit important information from microbiome studies to design endometriosis treatment strategies and disease biomarkers with the use of advanced molecular technologies and increased computational capacity. Future studies into the functional profile of the microbiome would greatly assist in the development of microbiome-based therapies to alleviate endometriosis symptoms and improve the quality of life of women suffering from endometriosis.

Ultrasonographic Findings Indirectly Predicting Parametrial Involvement in Patients with Deep Endometriosis: The ULTRA-PARAMETRENDO I Study

STUDY OBJECTIVE

To evaluate ultrasonographic findings as a first-line imaging tool to indirectly predict the presence of parametrial endometriosis (PE) in women with suspected deep endometriosis (DE) undergoing surgery.

DESIGN

Retrospective analysis of a prospectively collected database (ULTRA-PARAMETRENDO I study; NCT05239871).

SETTING

Referral center for DE.

PATIENTS

Consecutive patients undergoing laparoscopic surgery for DE.

INTERVENTIONS

Preoperative transvaginal ultrasonography was done according to the International Deep Endometriosis Analysis consensus statement. A stepwise forward regression analysis was performed considering the simultaneous presence of DE nodules and the following ultrasonographic indirect signs of DE: diffuse adenomyosis, endometriomas, ovary fixed to the lateral pelvic wall or the uterine wall, absence of anterior/posterior sliding sign, and hydronephrosis. The gold standard for the presence of PE was surgery with histologic confirmation.

MEASUREMENTS AND MAIN RESULTS

Of 1079 patients, 212 had a surgical diagnosis of PE (left: 18.5%; right: 17.0%; bilateral: 15.9%). The obtained prediction model (χ² = 222.530; p <.001) for PE included, as independent indirect DE signs presence of hydronephrosis (odds ratio [OR] = 14.5; p = .002), complete absence of posterior sliding sign (OR = 3.3; p <.001), presence of multiple endometriomas per ovary (OR = 3.0; p = .001), and ovary fixation to the uterine wall (OR = 2.4; p <.001); as independent concomitant DE nodules, presence of uterosacral nodules with the largest diameter >10 mm (OR = 3.2; p <.001), presence of rectal endometriosis with the largest diameter >25 mm (OR = 2.3; p = .004), and rectovaginal septum infiltration (OR = 2.3; p = .003). The optimal diagnostic balance was obtained considering at least 2 concomitant DE nodules and at least 1 indirect DE sign (area under the curve 0.75; 95% confidence interval, 0.72-0.79).

CONCLUSION

Specific indirect ultrasonographic findings should raise suspicion of PE in women undergoing preoperative assessment for DE. The suspicion of parametrial invasion may be critical to address patients to expert leading centers, where proper diagnosis and surgical treatment for PE can be performed.

Accuracy of combined physical examination, transvaginal ultrasonography, and magnetic resonance imaging to diagnose deep endometriosis

OBJECTIVES

To assess the ability of physical examination (PE), transvaginal ultrasonography (TVUS), and magnetic resonance imaging (MRI) alone and combined to diagnose deep infiltrating endometriosis (DIE).

DESIGN

We retrospectively queried our pelvic MRI database to identify women who underwent PE, TVUS, and pelvic MRI for DIE up to 12 months before surgery between January 1, 2016 and August 31, 2020. The presence of uterosacral ligaments (USL), vaginal, rectosigmoid (RS), parametrial, or sacrorectogenital septum (lateral) DIE shown by PE, TVUS, and MRI were correlated with surgical and histological findings.

SETTING

Academic hospital.

PATIENT(S)

We included 178 patients.

INTERVENTION(S)

Clinical and imaging evaluation of women who were diagnosed at surgery with deep pelvic endometriosis.

MAIN OUTCOME MEASURE(S)

The sensitivity, specificity, positive and negative predictive values, and accuracy of each technique separately and combined were assessed for each location. When the 3 techniques were combined, 2 models were tested as follows: all 3 techniques positive and concordant; and ≥2 techniques positive and concordant.

RESULT(S)

The prevalence of USL, vaginal, RS, and lateral DIE were 94.4%, 20.2%, 34.3%, and 32.6%, respectively. In addition, MRI was more sensitive than PE, TVUS or any combination to detect DIE. Moreover, MRI and model B were the most accurate for detecting USL and RS locations with an accuracy of 90.4% and 82.6%, a sensitivity of 91.1% and 50%, and a specificity of 77.8% and 90.9%, respectively. Model B was the most accurate for the vaginal location with an accuracy, sensitivity, and specificity of 82.6%, 50%, and 90.9%, respectively. Finally, MRI was more accurate than any combination for identifying a lateral location with an accuracy, sensitivity, and specificity of 75.1%, 36%, and 93.8%, respectively.

CONCLUSION(S)

A combination of PE, TVUS, and MRI was more accurate than each technique separately to diagnose DIE because of the equally high sensitivity of each, as well as the high specificity of PE and TVUS.

Advances in Imaging for Assessing Pelvic Endometriosis

In recent years, due to the development of standardized diagnostic protocols associated with an improvement in the associated technology, the diagnosis of pelvic endometriosis using imaging is becoming a reality. In particular, transvaginal ultrasound and magnetic resonance are today the two imaging techniques that can accurately identify the majority of the phenotypes of endometriosis. This review focuses not only on these most common imaging modalities but also on some additional radiological techniques that were proposed for rectosigmoid colon endometriosis, such as double-contrast barium enema, rectal endoscopic ultrasonography, multidetector computed tomography enema, computed tomography colonography and positron emission tomography-computed tomography with 16α-[18F]fluoro-17β-estradiol.

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 &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Reconsidering evidence-based management of endometriosis

Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised. Objectives: To review and discuss evidence in endometriosis management Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis. Results: Good-quality evidence is limited in endometriosis. Conclusions: Clinical experience remains undervalued especially for surgery. What is new? Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.

Ultrasound Evaluation of Retrocervical and Parametrial Deep Endometriosis on the Basis of Surgical Anatomical Landmarks

STUDY OBJECTIVES

To assess the value of combined transvaginal/transabdominal (TV/TA) ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas, and summarize the features and anatomical criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments.

DESIGN

Retrospective study.

SETTING

A specialized endometriosis center in Avellino, Italy PATIENTS: A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention.

INTERVENTIONS

Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals (CIs).

MEASUREMENTS AND MAIN RESULTS

A total of 4,983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97%-98% and 98%-100%, respectively, for both retrocervical (torus uterinus, uterosacral ligaments insertion) and parametrial lesions.

CONCLUSION

Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.