Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis

Advances in the diagnosis and management of endometriosis: A comprehensive review

Endometriosis is a prevalent gynecological condition characterized by the presence of endometrial-like tissue outside the uterus, leading to chronic pelvic pain and infertility. This review aims to shed light on the latest advancements in diagnosing and managing endometriosis. It offers insight into the condition's pathogenesis, clinical symptoms, diagnostic techniques, and available treatment approaches. Furthermore, the article emphasizes innovative technologies and novel therapeutic strategies that promise to enhance patient outcomes significantly. This review aspires to empower clinicians to deliver the highest quality care to their patients affected by this challenging condition by consolidating the current understanding of endometriosis.

Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting

Endometriosis is a common condition impacting approximately 190 million individuals and up to 50% of women with infertility globally. The disease is characterized by endometrial-like tissue located outside of the uterine corpus, which causes cyclical hemorrhage, inflammation, and fibrosis. Based on clinical suspicion or findings at routine transvaginal pelvic US or other prior imaging, dedicated imaging for endometriosis may be warranted with MRI or advanced transvaginal US. Deep endometriosis (DE) in the pelvis includes evaluation for stromal and fibrotic components and architectural distortion resulting from fibrosis and tethering. It is a disease requiring a compartment-based, pattern-recognition approach. MRI has the benefit of global assessment of the pelvis and is effective in assessing for features of malignancy and for evaluating extrapelvic locations. Transvaginal US has the advantage of dynamic maneuvers to assess for adhesions and may achieve higher spatial resolution for assessing the depth of bowel wall invasion. T1-weighted MRI evaluation increases the specificity of diagnosis by identifying hemorrhagic components, but the presence of T1 signal hyperintensity is not essential for diagnosing DE. Endometriosis is a disease with a broad spectrum; understanding the mild through advanced manifestations, including malignancy evaluation, is within the scope and breadth of radiologists' interpretation.

Bladder Endometriosis: What do we know and what is left to find out? A narrative review

Bladder endometriosis accounts for 70-85% of urinary tract endometriosis cases. Urinary tract endometriosis occurs in approximately 1% of those living with endometriosis. Underlying aetiology and pathogenesis are not fully understood, but there are several plausible theories. As well as the typical pain symptoms, those with bladder endometriosis can experience several urinary tract symptoms. The manifestation of these symptoms can have complex pathways and processes. Imaging is accurate in the diagnosis of bladder endometriosis and clinicians should be mindful of the risk of silent kidney loss. Management should be guided by symptoms; both medical and surgical options are feasible. Surgical management offers potentially definitive treatment. Excisional surgery via bladder shave or partial cystectomy offers good improvement in symptoms with relatively low rates of serious complications and recurrence.

Non-Invasive Imaging Techniques for Diagnosis of Pelvic Deep Endometriosis and Endometriosis Classification Systems: An International Consensus Statement

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counseling and planning of surgical treatment strategies.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: An International Consensus Statement

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counseling and planning of surgical treatment strategies. This Consensus Statement should be cited as: 'G. Condous, B. Gerges, I. Thomassin-Naggara, C. Becker, C. Tomassetti, H. Krentel, B.J. van Herendael, M. Malzoni, M. S. Abrao, E. Saridogan, J. Keckstein, G. Hudelist and Collaborators. Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: An International Consensus Statement. Eur. J. Radiol. 2024. https://doi.org/10.1016/j.ejrad.2024.111450.'

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counseling and planning of surgical treatment strategies. © 2024 The Authors. Published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology, by Universa Press, by The International Society for Gynecologic Endoscopy, by Oxford University Press on behalf of European Society of Human Reproduction and Embryology, by Elsevier Inc. on behalf of American Association of Gynecologic Laparoscopists and by Elsevier B.V.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement†,‡

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on a review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counselling and planning of surgical treatment strategies.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement. Hum Reprod Open 2024;2024:hoae029. [PMID: 38812884 PMCID: PMC11134890 DOI: 10.1093/hropen/hoae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), ESHRE, the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers, and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counselling, and planning of surgical treatment strategies.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

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.

Anatomical distribution of endometriosis: A cross-sectional analysis of transvaginal ultrasound in symptomatic patients

Purpose

The anatomical distribution of deep endometriosis (DE) is essential in treating patients with symptoms associated with the disease. There is an evidence gap in correlating clinical features and symptoms with disease patterns. The study aimed at determining DE anatomic distribution based on advanced transvaginal ultrasound and describe the relationship with symptoms obtained with the World Endometriosis Foundation Questionnaire.

Methods

A cross-sectional study included 549 ultrasound results and 370 questionnaire responses between July 2018 and January 2021. Descriptive statistics are presented. Continuous variables were compared by a simple t-test and ANOVA and categorical variables by the chi-squared test. Logistic regression and R2 values summarised the relationship between positive ultrasound and possible predictor variables (software SAS version 9.4).

Results

The anatomical locations with signs of endometriosis on ultrasound were the right uterosacral ligament (USL) 23.3% (n = 128), left USL 21.3% (n = 117) and bowel 19.1% (n = 105). Endometriomas in the right and left ovaries (14%, n = 77, and 14.7%, n = 81 respectively), superficial endometriosis in 15.5% (n = 85), torus uterinus in 11.7% (n = 64), Pouch of Douglas (POD) in 9.7% (n = 53), rectovaginal septum in 4.2% (n = 23), vaginal fornix in 3.5% (n = 19). A negative 'sliding-sign' was noted in 25.3% (n = 139), and ovarian medial immobility was noted frequently (left 20.2%, n = 111 and right 16.9%, n = 93). Dyspareunia, dysmenorrhoea, infertility and family history were associated with endometriosis lesions (P < 0.05). Prediction models based on symptomatology presented low discriminatory power.

Discussion

This large real-life cohort associating the description of the anatomical distribution of endometriosis as seen on advanced TVS in symptomatic patients confirmed that uterosacral ligaments, torus uterinus, ovaries and bowel represent the most common anatomical sites of endometriosis. Also, the dynamic abnormalities elicited via ultrasound, such as the uterus 'sliding-sign' and ovarian mobility, remain common. The knowledge of the general locations of identifiable endometriosis on ultrasound and the dynamic abnormalities is essential to sonologists and sonographers in implementing advanced TVS protocols to detect endometriosis. In addition, the different presentations of dyspareunia can be associated with USL and bowel endometriosis. Subfertility might also be associated with USL, ovarian and bowel endometriosis. Nevertheless, prediction models showed suboptimal results.

Conclusions

Endometriosis is mainly distributed in USLs, bowel and ovaries. POD obliteration is frequent. Symptoms can be associated with anatomic locations; however, prediction models showed low clinical applicability.

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.

Transvaginal Ultrasound in the Diagnosis and Assessment of Endometriosis-An Overview: How, Why, and When

Endometriosis is a common gynaecological disease, causing symptoms such as pelvic pain and infertility. Accurate diagnosis and assessment are often challenging. Transvaginal ultrasound (TVS), along with magnetic resonance imaging (MRI), are the most common imaging modalities. In this narrative review, we present the evidence behind the role of TVS in the diagnosis and assessment of endometriosis. We recognize three forms of endometriosis: Ovarian endometriomas (OMAs) can be adequately assessed by transvaginal ultrasound. Superficial peritoneal endometriosis (SUP) is challenging to diagnose by either imaging modality. TVS, in the hands of appropriately trained clinicians, appears to be non-inferior to MRI in the diagnosis and assessment of deep infiltrating endometriosis (DIE). The IDEA consensus standardized the terminology and offered a structured approach in the assessment of endometriosis by ultrasound. TVS can be used in the non-invasive staging of endometriosis using the available classification systems (rASRM, #ENZIAN). Given its satisfactory overall diagnostic accuracy, wide availability, and low cost, it should be considered as the first-line imaging modality in the diagnosis and assessment of endometriosis. Modifications to the original ultrasound technique can be employed on a case-by-case basis. Improved training and future advances in ultrasound technology are likely to further increase its diagnostic performance.

Effectiveness of ultrasound for endometriosis diagnosis

PURPOSE OF REVIEW

Endometriosis is a chronic benign gynaecological condition characterized by pelvic pain, subfertility and delay in diagnosis. There is an emerging philosophical shift from gold standard histopathological diagnosis through laparoscopy to establishing diagnosis through noninvasive imaging.

RECENT FINDINGS

The ENZIAN classification system was updated in 2021 to be suitable for both diagnostic imaging and laparoscopy. The accuracy of transvaginal ultrasound (TVUS) in diagnosing endometriosis varies depending on location of the lesion. A recent international pilot study found that when ultrasound is performed in accordance with the IDEA consensus, a higher detection of deep endometriosis is seen, with an overall sensitivity of 88% and specificity of 79% compared with direct surgical visualization.

SUMMARY

Although ultrasound can detect adenomyosis, deep endometriosis and endometriomas, it is not possible to reliably detect superficial endometriosis. In the instance of a negative ultrasound with persistence of symptoms despite medical therapy, laparoscopy should be considered for diagnosis and treatment.

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.

What is the accuracy of transvaginal ultrasound for endometriosis mapping prior to surgery when performed by a sonographer within an outpatient women's imaging centre?

INTRODUCTION

This study aimed to assess the accuracy of transvaginal ultrasound (TVUS) for the mapping of endometriosis before surgery when performed by sonographers in an outpatient women's imaging centre.

METHODS

A prospective longitudinal cohort study was performed. The study group comprised of 201 women who underwent a comprehensive TVUS assessment, performed by a sonographer. Laparoscopy was performed as the reference standard. Complete TVUS and surgical data were available for 53 women who were included in the final analysis.

RESULTS

Endometriosis was confirmed at a surgery in 50/53 (94.3%) participants, with 25/53 (47.2%) having deep endometriosis (DE) nodules and/or endometriomas present. TVUS for mapping of DE had an overall sensitivity of 84.0%, specificity of 89.3%, PPV of 87.5%, NPV of 86.2%, LR+ of 7.85, LR- of 0.18, and accuracy of 86.8% (P < 0.001). Ovarian immobility had poor sensitivity for detecting localised superficial endometriosis, DE, adhesions, and/or endometriomas (Left = 61.9% and right = 13.3%) but high specificities (left = 87.5% and right = 94.7%). Site-specific tenderness had low sensitivities and moderate specificities for the same. All soft markers of endometriosis failed to reach statistical significance except for left ovarian immobility (P = <0.001).

CONCLUSION

Sonographers well experienced in obstetric and gynaecological imaging, working in an outpatient women's imaging setting can accurately map DE; however, the performance of soft markers for detection of SE was poor.

'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis

Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.

Long-term conservative management of symptomatic bladder endometriosis: A case series of 17 patients

OBJECTIVES

This study aimed to evaluate the course of long-term conservative management of bladder endometriosis (BE).

MATERIALS AND METHODS

We retrospectively reviewed 17 cases of BE conservatively managed without surgery in our facility. The following factors were analyzed: age, medical history, lesion size, symptoms, hormonal treatment, and follow-up outcomes.

RESULTS

In this study, 15 patients received hormonal therapy and 2 did not. Oral contraceptive (OC), dienogest (DNG), and gonadotropin-releasing hormone agonist (GnRHa) were administered as the first regimen in 7, 5, and 3 patients, respectively. Of the 7 patients, OC administration was effective in alleviating urinary symptoms in all but 2 patients. Of 3 patients who received GnRHa, 2 switched to OC and then DNG, and 1 patient discontinued the treatment because of adverse effects. Of 5 patients who received DNG, all experienced symptom relief. DNG, OC, and GnRHa administration were effective and tolerable in 9 of 10 patients (90.0%), in 5 of 9 patients (55.6%), and in 2 of 3 patients (66.7%), respectively. In particular, 3 patients completed DNG treatment until menopause. The size of the BE lesion significantly decreased after 3 months of DNG administration, and the reduction effect was maintained until 48 months thereafter.

CONCLUSION

This study proposed that hormonal therapy for BE is an effective option for those who are not planning to conceive or to undergo surgery. Specifically, DNG may be suitable for patients refusing surgery, considering the effectiveness and tolerance for long-term use.

Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study

OBJECTIVE

To compare the preoperative detection of endometriosis using transvaginal sonography (TVS) supplemented by transabdominal sonography (TAS) with surgical assessment of disease, using the #Enzian classification for endometriosis.

METHODS

This was a prospective multicenter diagnostic accuracy study of women undergoing TVS/TAS and radical surgery for deep endometriosis (DE) at different tertiary referral centers. The localization and grade of severity of the endometriotic lesions and adhesions were described according to the criteria of the #Enzian classification, both at preoperative ultrasound examination and during surgery. According to the #Enzian classification, the small pelvis is divided into three compartments for DE: A (rectovaginal septum and vagina); B (uterosacral and cardinal ligaments, parametrium and pelvic sidewalls); and C (rectum). In addition, further locations (F) are classified as adenomyosis (FA), urinary bladder involvement (FB) and ureteric involvement with signs of obstruction (FU). Other intestinal locations (FI) and other extragenital locations (FO) are also included. Ovarian endometriosis and adhesions at the level of the tubo-ovarian unit are listed as O and T, respectively. The #Enzian grade of severity (Grade 1-3) was determined for #Enzian compartments O, T, A, B and C based on the size of the lesion or the severity of the adhesions. Concordance between preoperative assessment using TVS/TAS and evaluation at surgery was assessed. The sensitivity, specificity, positive and negative predictive values and accuracy of TVS/TAS in the detection of endometriotic lesions/adhesions in the different #Enzian compartments were calculated.

RESULTS

In total, 745 women were included in the analysis. Preoperative TVS/TAS and surgical findings showed a concordance rate ranging between 86% and 99% for the presence or absence of endometriotic lesions/adhesions, depending on the evaluated #Enzian compartment. The concordance rate between TVS and surgery ranged between 71% and 92% for different severity grades, in #Enzian compartments O, T, A, B and C. Determining the presence or absence of adhesions at the level of the tubo-ovarian unit and classifying them accurately as Grade 1, 2 or 3 on TVS was more difficult than determining the presence and severity of endometriotic lesions in #Enzian compartments O, A, B and C. The sensitivity of TVS/TAS for the detection of endometriotic lesions ranged from 50% (#Enzian compartment FI) to 95% (#Enzian compartment A), specificity from 86% (#Enzian compartment T_left ) to 99% (#Enzian compartment FI) and 100% (#Enzian compartments FB, FU and FO), positive predictive value from 90% (#Enzian compartment T_right ) to 100% (#Enzian compartment FO), negative predictive value from 74% (#Enzian compartment B_left ) to 99% (#Enzian compartments FB and FU) and accuracy from 88% (#Enzian compartment B_right ) to 99% (#Enzian compartment FB).

CONCLUSIONS

The localization and severity of endometriotic lesions/adhesions, as described and classified according to the #Enzian classification, can be diagnosed accurately and non-invasively using TVS/TAS. The #Enzian classification provides a uniform classification system for describing endometriotic lesions, which can be used both at TVS/TAS and during surgical evaluation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

How long does a transvaginal ultrasound examination for endometriosis take in comparison to a routine transvaginal ultrasound examination?

INTRODUCTION

This study aimed to determine the additional time needed to perform an endometriosis transvaginal ultrasound (eTVUS) compared to routine transvaginal ultrasound (rTVUS).

METHODS

A retrospective case-control study was performed. The study group included 199 eTVUS performed between September 2019 and September 2020. The control group comprised 105 consecutive rTVUS studies performed in the same time period. The time stamps on the ultrasound images of all cases in both groups were reviewed to determine the time taken to perform each study. Mean, median, minimum and maximum scan times for both groups were calculated as was percentage difference between scan times. A two-tailed, unpaired t-test of the normalised data and a Mann-Whitney U test assessing time difference of scans between two groups were performed with P value <0.05 considered statistically significant.

RESULTS

Performing eTVUS took significantly longer than rTVUS with increases in the mean (8.4 vs 13.8 min, 64%), median (7 vs 12 min, 71%), minimum (4 vs 7 min, 75%) and maximum (19 vs 42 min, 121%) scan times. The Mann-Whitney U test indicated a statistically significant difference in the median scan times (5.0, CI 4.0-6.0), P < 0.001. An independent t-test of the normalised data revealed a significantly larger mean scan time for eTVUS than rTVUS, Mean = 9.05 95%CI [13.17-4.94], t(302) = 4.327, P < 0.001. R 2 = 0.583.

CONCLUSION

Endometriosis transvaginal ultrasound added an average 5.4 min to rTVUS, which is statistically significant. For ultrasound departments wanting to offer this technique, doubling the scan time allocated to perform a transvaginal ultrasound (TVUS) is suggested.

What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis

BACKGROUND

Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging).

OBJECTIVES

To highlight the advantages and disadvantages of the three classification systems.

METHODS

This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis.

CONCLUSIONS

A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.