Structured report for dynamic ultrasonography in patients with suspected or known endometriosis: Recommendations of the International Society for Gynecologic Endoscopy (ISGE)

Clues to revising the conventional diagnostic algorithm for endometriosis

Endometriosis is a complex gynecologic disorder characterized primarily by symptoms of pelvic pain, infertility, and altered quality of life. National and international guidelines highlight the diagnostic difficulties and lack of conclusive diagnostic tools for endometriosis. Furthermore, guidelines are becoming questionable at an increasingly rapid rate as new diagnostic techniques emerge. This work aims to provide a knowledge synthesis of the relevance of various diagnostic tools and to assess areas of improvement of conventional algorithms. MEDLINE and Cochrane Library databases were searched from January 2021 to December 2023 using relevant key words. Articles evaluating the diagnostic relevance and performance of various tools were included and independently reviewed by the authors for eligibility. Included studies were assessed using the GRADE and QUADAS-2 tools. Of the 4204 retrieved articles, 26 were included. While anamnesis and clinical examination do contribute to diagnostic accuracy, their level of evidence and impact on the diagnostic process remains limited. Although imaging techniques are recommended to investigate endometriosis, ultrasonography remains highly operator dependent. Magnetic resonance imaging appears to exhibit higher sensitivities than ultrasound. However, concerns persist with regards to the terminology, anatomical definition of lesions, and accuracies of both ultrasound and magnetic resonance imaging. Recently, several biological markers have been studied and cumulative evidence supports the contribution of noncoding RNAs to the diagnosis of endometriosis. Marginal improvements have been suggested for anamnesis, clinical examination, and imaging examinations. Conversely, some biomarkers, including the saliva microRNA signature for endometriosis, have emerged as diagnostic tools which inspire reflection on the revision of conventional diagnostic algorithms.

The expanding role of sonography for the diagnosis of deep infiltrating endometriosis: Results of a large case series

OBJECTIVE

To investigate the value of the sonographic identification of deep infiltrating endometriosis (DIE) in women presenting with complaints suggestive of DIE. Sonography findings were correlated with subsequent surgical exploration, and histologic verification.

METHODS

A retrospective observational case series was investigated to document the ability of the use of sonography to accurately detect the presence of deep infiltrating endometriosis. The clinical observations were performed consistent with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations for observational studies. Recognizing the real-world office setting for this may introduce the importance of the practical clinical aspects of diagnostic procedures in general.

RESULTS

Three-dimensional transvaginal sonography was able to accurately identify deep invasive endometriosis in 92% of the 100 women subjectively complaining of the associated symptoms of endometriosis, who underwent sonography, surgical exploration, and pathologic analysis. Additional sonographic evidence of pelvic pathology was found during the course of this investigation, perhaps complementing other means for diagnosing endometriosis.

CONCLUSION

Three-dimensional transvaginal sonography is a diagnostic tool that can effectively identify deep infiltrating endometriosis, which may otherwise go undetected and untreated. These findings should encourage the use of sonography for the detection of this subtype of endometriosis.

MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report

Endometriosis represents one of the most common causes of life-impacting chronic pelvic pain and female infertility. Magnetic resonance imaging (MRI) plays an increasing role in the diagnosis and mapping of endometriosis, while diagnostic laparoscopy currently tends to be reserved for the patients with negative imaging results. The #Enzian, published in 2021, proposes a new comprehensive classification system of endometriosis, combining a complete staging of deep infiltrative endometriosis with the evaluation of peritoneal/ovarian/tubal localizations and the presence of adenomyosis. This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis. Overall, there is a significant matching between MRI features and the #Enzian classification criteria, two different perspectives of endometriosis mapping, with different goals and levels of detail. The main discrepancy lies in the evaluation of tubo-ovarian condition, which is not fully assessable by MRI. Furthermore, as endometriosis is a complex disease, usually multifocal, that can present with a myriad of imaging findings, MRI reporting should be clear and well organized. The authors group, both radiologists and gynecologists, propose a structured MRI report of endometriosis in correlation with the #Enzian classification, merging the detailed anatomical and pre-operative information provided by the MRI with the benefits of a comprehensive classification system of endometriosis in the clinical practice and research field.Critical relevance statement This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis and proposes a #Enzian-based structured MRI report.

Pre-operative mapping and structured reporting of pelvic endometriotic lesions on dynamic ultrasound and its correlation on laparoscopy using the #ENZIAN classification

PURPOSE

The objective of this study was to evaluate and compare the diagnostic performance of ultrasonography (USG) assessment using structured reporting with intraoperative laparoscopic assessment in deep infiltrating endometriosis (DIE) using the recent update of the #ENZIAN classification.

METHODS

This was a retrospective study conducted in Tertiary Multi-disciplinary Endometriosis Care Hospital over a period of 8 months which included 50 patients who underwent a planned laparoscopic endometriosis excisional surgery after a dedicated USG assessment using International Deep Endometriosis Analysis (IDEA) protocol and #ENZIAN score (updated ENZIAN classification), between Feb 2021 and Sept 2021 at Apollo Hospitals, Hyderabad. The pre-operative USG findings were reported in a structured reporting format and intraoperative findings were classified using the standard #ENZIAN classification. No prospective interventions were done. A review of pre-operative ultrasound and laparoscopic findings as per the #ENZIAN was done.

RESULTS

Sensitivity and the negative predictive value of ultrasound were 86% and 84.2% for peritoneal lesions, 97% and 93.3% for left ovarian lesions, 93% and 91.6% for right ovarian lesions, 91% and 84% for left tubal lesions, 90% and 86.3% for right tubal lesions, 93% and 75% for uterosacral ligaments, 93.3% and 97% for rectal lesions and sensitivity and negative predictive values were 100% for rectovaginal lesions, adenomyosis, and ureteric lesions as confirmed on laparoscopy.

CONCLUSION

Dynamic ultrasound assessment with a structured report based on IDEA protocol and #ENZIAN score is accurate for mapping of pelvic endometriosis in all forms, and it correlates with laparoscopic findings, thus helps surgeon for better planning and providing a road map for surgeons. From a clinical perspective, a uniform and shared reporting system across imaging and therapeutic modalities will simplify communication, improving patient management by conservative or surgical treatments, avoiding multiple repeat surgeries, and improving quality of treatment.

Surgical Treatment of Deep Endometriosis

In deep endometriosis (DE), clusters of endometrium-like cells penetrate more than 5 mm below the peritoneum: The affected organs and tissue structures can eventuate in an alteration of the anatomy with eliminated organ boundaries, which in some cases can pose a real surgical challenge, even for experienced surgeons. A comprehensive description of the different manifestations of the disease can be found in the #Enzian classification. Since the operation is usually the foundation for the successful treatment of DE, what is important are conclusive indications, appropriate preoperative preparation and, above all, appropriate experience on the part of the surgical team. This article aims to provide a review of the surgical options that are currently available.

Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis

Gynecological ultrasonography plays a central role in the management of endometriosis. The rapid technical development as well as the currently increasing evidence for non-invasive diagnostic methods require an updated compilation of recommendations for the use of ultrasound in the management of endometriosis. The present work aims to highlight the accuracy of sonography for diagnosing and classifying endometriosis and will formulate the present list of key messages and recommendations. This paper aims to demonstrate the accuracy of TVS in the diagnosis and classification of endometriosis and to discuss the clinical applications and consequences of TVS findings for indication, surgical planning and assessment of associated risk factors. (1) Sophisticated ultrasound is the primary imaging modality recommended for suspected endometriosis. The examination procedure should be performed according to the IDEA Consensus. (2) Surgical intervention to confirm the diagnosis alone is not recommended. A preoperative imaging procedure with TVS and/or MRI is strongly recommended. (3) Ultrasound examination does not allow the definitive exclusion of endometriosis. (4) The examination is primarily transvaginal and should always be combined with a speculum and a bimanual examination. (5) Additional transabdominal ultrasonography may enhance the accuracy of the examination in case of extra pelvic disease, extensive findings or limited transvaginal access. (6) Sonographic assessment of both kidneys is mandatory when deep endometriosis (DE) and endometrioma are suspected. (7) Endometriomas are well defined by sonographic criteria. When evaluating the ovaries, the use of IOTA criteria is recommended. (8) The description of sonographic findings of deep endometriosis should be systematically recorded and performed using IDEA terminology. (9) Adenomyosis uteri has sonographically well-defined criteria (MUSA) that allow for detection with high sensitivity and specificity. MRI is not superior to differentiated skilled ultrasonography. (10) Classification of the extent of findings should be done according to the #Enzian classification. The current data situation proves the best possible prediction of the intraoperative situs of endometriosis (exclusive peritoneum) for the non-invasive application of the #Enzian classification. (11) Transvaginal sonographic examination by an experienced examiner is not inferior to MRI diagnostics regarding sensitivity and specificity in the prediction of the extent of deep endometriosis. (12) The major advantage of non-invasive imaging and classification of endometriosis is the differentiated planning or possible avoidance of surgical interventions. The recommendations represent the opinion of experts in the field of non-invasive and invasive diagnostics as well as therapy of endometriosis. They were developed with the participation of the following national and international societies: DEGUM, ÖGUM, SGUM, SEF, AGEM/DGGG, and EEL.

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.

The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult

PURPOSE OF REVIEW

Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic disorders. To date, no formal recommendations have been made in defining a referral system for MIGS. This article reviews the evidence regarding common disorders and procedures and their outcomes, and posits a basis for MIGS referral.

RECENT FINDINGS

In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes, and therefore, benefit from the skills of MIGS subspecialists: fibroids - at least five myomas, myoma size at least 9 cm, and suspected myoma weight at least 500 g; endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; hysterectomy - uteri at least 250 g or 12 weeks estimated size, at least three prior laparotomies, obesity, and complex surgical history with suspected adhesive disease.

SUMMARY

A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

Molecular Basis of Endometriosis and Endometrial Cancer: Current Knowledge and Future Perspectives

The human endometrium is a unique tissue undergoing important changes through the menstrual cycle. Under the exposure of different risk factors in a woman's lifetime, normal endometrial tissue can give rise to multiple pathologic conditions, including endometriosis and endometrial cancer. Etiology and pathophysiologic changes behind such conditions remain largely unclear. This review summarizes the current knowledge of the pathophysiology of endometriosis and its potential role in the development of endometrial cancer from a molecular perspective. A better understanding of the molecular basis of endometriosis and its role in the development of endometrial pathology will improve the approach to clinical management.