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Bandini V, Giola F, Ambruoso D, Cipriani S, Chiaffarino F, Vercellini P. The natural evolution of untreated deep endometriosis and the effect of hormonal suppression: A systematic literature review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1722-1735. [PMID: 38867640 PMCID: PMC11324912 DOI: 10.1111/aogs.14887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Peritoneal infiltrating and fibrotic endometriosis, also known as deep endometriosis, is the most severe manifestation of the disease that can cause severe complications including bowel and ureteral stenosis. The natural history of these lesions and the possible effect of hormonal treatments on their progression are undefined. Therefore, we conducted a systematic review and meta-analysis to investigate whether and how frequently deep endometriosis progresses over time without or with ovarian suppression. This could inform management decisions in asymptomatic and mildly symptomatic patients. MATERIAL AND METHODS For this pre-registered systematic review (CRD42023463518), the PubMed and Embase databases were screened, and studies published between 2000 and 2023 that serially evaluated the size of deep endometriotic lesions without or with hormonal treatment were selected. Data on the progression, stability, or regression of deep endometriotic lesions were recorded as absolute frequencies or mean volume variations. Estimates of the overall percentage of progression and corresponding 95% confidence intervals were calculated using a random-effect model. When studies reported lesion progression as pre- and post-treatment volume means, the delta of the two-volume means was calculated and analyzed using the inverse variance method. RESULTS A total of 29 studies were identified, of which 19 studies with 285 untreated and 730 treated patients were ultimately selected for meta-analysis. The overall estimate of the percentage of lesion progression in untreated individuals was 21.4% (95% CI, 6.8-40.8%; I2 = 90.5%), whereas it was 12.4% during various hormonal treatments (95% CI, 9.0-16.1%; I2 = 0%). Based on the overall meta-analysis estimates, the odds ratio of progression in treated vs untreated patients was 0.52 (95% CI, 0.41-0.66). During hormonal suppression, the mean volume of deep endometriotic lesions decreased significantly by 0.87 cm3 (95% CI, 0.19-1.56 cm3; I2 = 0%), representing -28.5% of the baseline volume. CONCLUSIONS Untreated deep endometriotic lesions progressed in about one in five patients. Medical therapy reduced but did not eliminate this risk. Given the organ function failure potentially caused by these lesions, the decision whether to use hormonal treatments in asymptomatic or mildly symptomatic women should always be shared, carefully weighing the potential benefits and harms of the two alternatives after extensive counseling.
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Affiliation(s)
- Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and EndometriosisUniversità degli StudiMilanItaly
| | - Francesca Giola
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and EndometriosisUniversità degli StudiMilanItaly
| | - Deborah Ambruoso
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and EndometriosisUniversità degli StudiMilanItaly
| | - Sonia Cipriani
- Gynecology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and EndometriosisUniversità degli StudiMilanItaly
- Gynecology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
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da Costa Porto BT, Ribeiro PA, Kuteken F, Ohara F, Abdalla Ribeiro HS. Levonorgestrel intrauterine system versus dienogest effect on quality of life of women with deep endometriosis: a randomized open-label clinical trial. Women Health 2024; 64:551-558. [PMID: 39111847 DOI: 10.1080/03630242.2024.2382418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 07/05/2024] [Accepted: 07/15/2024] [Indexed: 08/20/2024]
Abstract
Women with deep infiltrating endometriosis (DIE) can benefit from the use of progestins. Our aim is to explore if levonorgestrel-releasing intrauterine system (LNG-IUS) non inferior to dienogest (DNG) in improving deep endometriosis women's quality of life (QoL). This randomized open-label clinical trial included forty women with DIE assessed using clinical history and physical examination, transvaginal ultrasonography and magnetic resonance of the pelvis without any previous surgical treatment, with two treatments arms. The two groups underwent a 3-month washout of hormonal treatments, and then received either DNG or LNG-IUS for 6 months. QoL was assessed prior to and 6 months after the intervention, using the SF36 and the EHP30. DNG and LNG-IUS showed an increase on all domains of the SF36 (p < .001). There was no difference between treatments on the improvement observed (p > .05 for all domains). DNG and LNG-IUS, also, showed improvement on all domains of EHP30 (p < .001), except "relationship with children" and "feelings about pregnancy." However, there was no statistical difference between treatments for all sections scores (p > .05). The treatment of deep endometriosis symptoms using either DNG or LNG-IUS in women with no prior surgical treatment is associated with improvement in QoL.Trial Registration Number: This trial is registered on "The Brazilian Registry of Clinical Trials (ReBECID: RBR-8fjx2jp)," that is part of Primary Registries in the WHO Registry Network, under the title: "Dienogest versus Levonorgestrel IUS on deep endometriosis patient´s QoL without surgery" on June 14, 2021; https://ensaiosclinicos.gov.br/rg/RBR-8fjx2jp.
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Affiliation(s)
| | - Paulo Ayroza Ribeiro
- Gynecological Endoscopy and Endometriosis Division Clinic, Santa Casa de Misericórdia do Brasil, São Paulo, Brasil
| | - Fábio Kuteken
- Gynecological Endoscopy and Endometriosis Division Clinic, Santa Casa de Misericórdia do Brasil, São Paulo, Brasil
| | - Fábio Ohara
- Gynecological Endoscopy and Endometriosis Division Clinic, Santa Casa de Misericórdia do Brasil, São Paulo, Brasil
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Forman A. Transvaginal ultrasound reliably detects and classifies most cases of deep endometriosis. Facts Views Vis Obgyn 2024; 16:125-126. [PMID: 38950528 DOI: 10.52054/fvvo.16.2.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
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Keckstein S, Dippon J, Hudelist G, Koninckx P, Condous G, Schroeder L, Keckstein J. Sonomorphologic Changes in Colorectal Deep Endometriosis: The Long-Term Impact of Age and Hormonal Treatment. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024; 45:285-292. [PMID: 38101445 DOI: 10.1055/a-2209-5653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
PURPOSE The progression of deep endometriosis (DE) in women of reproductive age is highly variable. This study aimed to analyze the sonomorphological changes of rectal endometriosis over long periods of time and the influence of hormonal treatment. METHODS This retrospective study included premenopausal women with rectal DE treated conservatively between 2002 and 2021. The lesion length and thickness of the nodule were evaluated at regular intervals over time. We created statistical models with mixed effects to identify potential factors influencing lesion progression and regression. RESULTS 38 patients were monitored over a mean period of 7.2 (± 4.2) years with a mean of 3.1 (± 2.1) check-ups within the observation period. We detected a significant increase in lesion length until the end of the fourth decade of life. In addition, we found a substantial decrease in the length and thickness of the nodule depending on the length of hormonal treatment. CONCLUSION In conservatively managed patients with rectal endometriosis, without hormonal therapy, lesion size can exhibit a moderate increase up to the end of the fourth decade of life, after which it appears to stabilize. This increase does not follow a linear pattern. Hormonal therapy is crucial in impeding further progression, resulting in either a cessation or a regression of lesion growth.
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Affiliation(s)
- Simon Keckstein
- Department of Obstetrics and Gynecology, LMU University Hospital, Munich, Germany
| | - Juergen Dippon
- Institute for Stochastics and Applications, University of Stuttgart, Stuttgart, Germany
| | | | - Philippe Koninckx
- Department for Gynecology, Latifa Hospital, Dubai, United Arab Emirates
| | - George Condous
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, University of Sydney - Sydney Medical School Nepean, Sydney, Australia
| | - Lennard Schroeder
- Department of Obstetrics and Gynecology, LMU University Hospital, Munich, Germany
| | - Joerg Keckstein
- (SEF), Stiftung Endometrioseforschung, Westerstede, Germany
- Gynecological Clinic, Gynecological Clinic Drs Keckstein, Villach, Austria
- Department of Obstetrics and Gynecology, Ulm University Hospital, Ulm, Germany
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Jones GL, Budds K, Taylor F, Musson D, Raymer J, Churchman D, Kennedy SH, Jenkinson C. A systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis. Hum Reprod Update 2024; 30:186-214. [PMID: 38007607 PMCID: PMC10905511 DOI: 10.1093/humupd/dmad029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/06/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND The Endometriosis Health Profiles (EHPs), the EHP-30 and EHP-5, are patient-reported outcome measures that were developed to measure the health-related quality of life (HRQoL) of women living with endometriosis. Prior to their development, a systematic review was undertaken which identified that the HRQoL of women living with endometriosis was poorly understood, with only three medical and one surgical study identified. OBJECTIVE AND RATIONALE The 20-year anniversary of the EHP-30 provided a timely opportunity to assess how the tools have been used and explore what the findings tell us about the impact of endometriosis and its associated treatments upon women's QoL. Applying robust systematic review methodology, following PRISMA guidelines, we sought to answer: How many studies have used the EHP and for what purpose?; What are the demographic characteristics and international context of the studies?; What is the methodological nature and quality of the studies?; Which interventions have been assessed and what are the reported EHP outcomes?; and Can the EHP outcomes of these interventions be analysed using a meta-analysis and, if so, what do the results show? SEARCH METHODS The electronic databases MEDLINE, CINAHL, PsycINFO, PubMed, and Google Scholar were searched from the year the EHP was first published, in 2001 to 26 February 2020 using the search terms 'EHP30', 'EHP5', 'EHP-30', 'EHP-5', 'endometriosis health profile 30', and 'endometriosis health profile 5'. We updated the searches on 9 April 2021. All included studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT). OUTCOMES The review included 139 papers. In clinical intervention studies, the EHPs were deployed most frequently to measure the outcomes of medical (n = 35) and surgical (n = 21) treatment. The EHPs were also used in 13 other intervention studies, 29 non-interventional studies, 32 psychometric/cross cultural validation studies; six diagnostic studies, and in three other studies to measure outcomes in related conditions. They were mainly deployed in studies undertaken in Europe and North America. Overall, regardless of the nature of the intervention, most women reported improvements in HRQoL after treatment. Surgical interventions generally resulted in significant improvements for the longest amount of time. There was also evidence that when participants stopped taking medication their EHP scores worsened, perhaps reinforcing the temporary impact of medical treatment. Younger patients reported more negative impact upon their HRQoL. Further evidence using classical test theory to support the EHPs' robust psychometric properties, including acceptability, dimensionality, reliability, validity (including cross-cultural), and responsiveness, was demonstrated, particularly for the EHP-30. Strikingly, using anchor-based methods, EHP-30 responsiveness studies demonstrate the largest mean changes in the 'control and powerlessness' domain post-intervention, followed by 'pain'. MMAT outcomes indicated the quality of the papers was good, with the exception of five studies. A meta-analysis was not undertaken owing to the heterogeneity of the interventions and papers included in this review. WIDER IMPLICATIONS Women with endometriosis face a lifetime of surgical and/or medical interventions to keep the condition under control. Less invasive treatments that can lead to improved longer term physical and psycho-social outcomes are needed. The EHPs are reliable, valid, acceptable, and responsive tools, but more assessment of EHP outcomes using modern psychometric methods and in the context of women from ethnically diverse backgrounds and in routine clinical care would be beneficial. Given the brevity of the EHP-5, it may be the most appropriate version to use in routine clinical practice, whereas the longer EHP-30, which provides more granularity, is more appropriate for research.
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Affiliation(s)
- Georgina L Jones
- Department of Psychology, School of Humanities and Social Sciences, Leeds Beckett University, Leeds, UK
| | - Kirsty Budds
- Department of Psychology, School of Humanities and Social Sciences, Leeds Beckett University, Leeds, UK
| | - Francesca Taylor
- Department of Psychology, School of Humanities and Social Sciences, Leeds Beckett University, Leeds, UK
| | - Danielle Musson
- Department of Psychology, School of Humanities and Social Sciences, Leeds Beckett University, Leeds, UK
| | | | | | - Stephen H Kennedy
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Avila-Tavares R, Gibran L, Brito LGO, Tavoni TM, Gonçalves MO, Baracat EC, Maranhão RC, Podgaec S. Pilot study of treatment of patients with deep infiltrative endometriosis with methotrexate carried in lipid nanoparticles. Arch Gynecol Obstet 2024; 309:659-667. [PMID: 37987824 DOI: 10.1007/s00404-023-07246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/27/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Previously, lipid nanoparticles (LDE) injected in women with endometriosis were shown to concentrate in the lesions. Here, the safety and feasibility of LDE carrying methotrexate (MTX) to treat deep infiltrating endometriosis was tested. DESIGN Prospective pilot study. SETTING Perola Byington Hospital Reference for Women's Health. SUBJECTS Eleven volunteers (aged 30-47 years, BMI 26.15 ± 6.50 kg/m2) with endometriosis with visual analog scale pelvic pain scores (VAS) > 7 and rectosigmoid lesions were enrolled in the study. INTERVENTION Three patients were treated with LDE-MTX at single intravenous 25 mg/m2 dose of MTX and eight patients with two 25 mg/m2 doses with 1-week interval. MAIN OUTCOME MEASURES Clinical complaints, blood count, and biochemistry were analyzed before treatment and on days 90, 120, and 180 after LDE-MTX administration. Endometriotic lesions were evaluated by pelvic and transvaginal ultrasound (TVUS) before treatment and on days 30 and 180 after LDE-MTX administration. RESULTS No clinical complaints related with LDE-MTX treatment were reported by the patients, and no hematologic, renal, or hepatic toxicities were observed in the laboratorial exams. FSH, LH, TSH, free T4, anti-Müllerian hormone, and prolactin levels were also within normal ranges during the observation period. Scores for deep dyspareunia (p < 0.001), chronic pelvic pain (p = 0.008), and dyschezia (p = 0.025) were improved over the 180-day observation period. There was a non-significant trend for reduction of VAS scores for dysmenorrhea. Bowel lesions by TVUS were unchanged. No clear differences between the two dose levels in therapeutic responses were observed. CONCLUSION Results support the safety and feasibility of using LDE-MTX in women with deep infiltrating endometriosis as a novel and promising therapy for the disease. More prolonged treatment schemes should be tested in future placebo-controlled studies aiming to establish the usefulness of this novel nanomedicine approach.
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Affiliation(s)
- Roberta Avila-Tavares
- Gynecological Endoscopy Center of the Perola Byington Hospital Reference for Women's Health, São Paulo, Brazil.
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.
| | - Luciano Gibran
- Gynecological Endoscopy Center of the Perola Byington Hospital Reference for Women's Health, São Paulo, Brazil
| | - Luiz Gustavo Oliveira Brito
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Thauany Martins Tavoni
- Lipid Metabolism Laboratory, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | | | - Edmund Chada Baracat
- Department of Obstetrics and Gynecology, Medical School Hospital, University of Sao Paulo, São Paulo, Brazil
| | | | - Sergio Podgaec
- Department of Obstetrics and Gynecology, Medical School Hospital, University of Sao Paulo, São Paulo, Brazil
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Mușat F, Păduraru DN, Bolocan A, Constantinescu A, Ion D, Andronic O. Endometriosis as an Uncommon Cause of Intestinal Obstruction-A Comprehensive Literature Review. J Clin Med 2023; 12:6376. [PMID: 37835020 PMCID: PMC10573381 DOI: 10.3390/jcm12196376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/20/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
The prevalence of intestinal endometriosis has been estimated to be between 3% and 37% of all endometriosis cases. Cases of intestinal occlusion due to endometriosis foci on the small bowel and on the large bowel are even rarer, with a reported prevalence of 0.1-0.7%. The aim of this literature review was to summarize the available published evidence on the diagnosis, characteristics, and management of intestinal occlusion due to endometriosis. The search on PubMed retrieved 295 records, of which 158 were rejected following a review of the title and abstract. After reviewing the full text, 97 studies met the Population, Intervention, Comparator, Outcomes, and Study (PICOS) criteria and were included in the analysis. The total number of patients with bowel occlusion due to endometriosis included in the studies was 107. The occlusive endometrial foci were localized on the ileum in 38.3% of the cases, on the rectosigmoid in 34.5% of the cases, at the ileocecal junction and the appendix in 14.9% of the cases, and at the rectum in 10.2% of the cases. Only one case reported large bowel obstruction by endometriosis of the hepatic flexure of the colon extending to the transverse colon (0.9%), and in one case the obstruction was caused by an omental giant endometrioid cyst compressing the intestines. We identified six cases of postmenopausal females with acute bowel obstruction due to endometriosis. Malignant degeneration of endometriosis was also identified as a cause of intestinal occlusion. The mechanisms of obstruction include the presence of a mass in the lumen of the intestine or in the wall of the intestine, extrinsic compression, adhesions, or intussusception.
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Affiliation(s)
- Florentina Mușat
- General Surgery Department, Carol Davila University of Medicine and Pharmacy, The University Emergency Hospital of Bucharest, 050098 Bucharest, Romania; (F.M.); (A.B.); (D.I.); (O.A.)
| | - Dan Nicolae Păduraru
- General Surgery Department, Carol Davila University of Medicine and Pharmacy, The University Emergency Hospital of Bucharest, 050098 Bucharest, Romania; (F.M.); (A.B.); (D.I.); (O.A.)
| | - Alexandra Bolocan
- General Surgery Department, Carol Davila University of Medicine and Pharmacy, The University Emergency Hospital of Bucharest, 050098 Bucharest, Romania; (F.M.); (A.B.); (D.I.); (O.A.)
| | - Alexandru Constantinescu
- Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, The University Emergency Hospital of Bucharest, 050098 Bucharest, Romania;
| | - Daniel Ion
- General Surgery Department, Carol Davila University of Medicine and Pharmacy, The University Emergency Hospital of Bucharest, 050098 Bucharest, Romania; (F.M.); (A.B.); (D.I.); (O.A.)
| | - Octavian Andronic
- General Surgery Department, Carol Davila University of Medicine and Pharmacy, The University Emergency Hospital of Bucharest, 050098 Bucharest, Romania; (F.M.); (A.B.); (D.I.); (O.A.)
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Hudelist G, Pashkunova D, Darici E, Rath A, Mitrowitz J, Dauser B, Senft B, Bokor A. Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - A prospective cohort study. Acta Obstet Gynecol Scand 2023; 102:1347-1358. [PMID: 37694901 PMCID: PMC10541157 DOI: 10.1111/aogs.14676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION There is an ongoing debate on surgical techniques for colorectal deep endometriosis (DE) and their effects on gastrointestinal (GI) function. The aim of this study was to prospectively investigate the differences in pre- and postsurgical GI function, health profiles and pain symptoms in women undergoing colorectal surgery for symptomatic DE either with a modified segmental resection technique, so-called nerve-vessel sparing segmental resection (NVSSR), or full thickness discoid resection (FTDR). Complication rates and fertility outcomes were also evaluated. MATERIAL AND METHODS A total of 162 consecutive patients, 125 (77.2%) of whom underwent NVSSR and 37 (22.8%) FTDR, were evaluated regarding complication rates. Furthermore a lower anterior resection syndrome (LARS) scores, gastrointestinal function-related quality of life index (GIQLI), pain symptoms, endometriosis health profile (EHP-30) parameters were analyzed pre- and post-surgery in a final cohort of 121 patients. RESULTS There was no difference between postsurgical prevalence of LARS in either surgery group (14/98, 14.1% NVSSR; 2/23, 8.6% FTDR), with significantly decreased LARS scores and increased GIQLI values before vs after surgery in both groups (P < 0.001). The overall grade III complication rate was 7/162 (4.3%) with no significant differences between NVSSR and FTDR groups. Overall, EHP-30 and pain scores significantly decreased after a median follow-up of 41 (± 17.6) months (EHP-30 51.1, SD 21.5 vs 12.7, SD 19.3, P < 0.001; dysmenorrhea, dyspareunia, dyschezia all P < 0.001 both cohorts, respectively). The overall life birth rate and postsurgical pregnancy in infertile patients undergoing NVSSR and FTDR was respectively 58.1% in 25/43 patients; 55.6% in 5/9 patients; 56.0% in 14/25 patients and 100% in 5/5 patients. CONCLUSIONS NVSSR and FTDR for symptomatic colorectal DE confer a significant amelioration of GI function reflected by decreased LARS symptoms and increased GIQLI scores with no differences in postsurgical function in between the two techniques. Both techniques confer similar complication rates and effects on pain reduction and health profiles.
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Affiliation(s)
- Gernot Hudelist
- Department of Gynecology, Center for EndometriosisHospital St. John of GodViennaAustria
- Rudolfinerhaus Private Clinic and CampusViennaAustria
| | - Daria Pashkunova
- Department of Gynecology, Center for EndometriosisHospital St. John of GodViennaAustria
| | - Ezgi Darici
- Brussels IVF, Centre for Reproductive Medicine Universitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Anna Rath
- Rudolfinerhaus Private Clinic and CampusViennaAustria
| | - Johanna Mitrowitz
- Department of Gynecology, Center for EndometriosisHospital St. John of GodViennaAustria
| | - Bernhard Dauser
- Department of General Surgery, Center for EndometriosisHospital St. John of GodViennaAustria
| | - Birgit Senft
- Statistix Statistical Calculations CompanyKlagenfurtAustria
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Center for EndometriosisSemmelweis University BudapestBudapestHungary
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Aas-Eng MK, Montanari E, Lieng M, Keckstein J, Hudelist G. Transvaginal Sonographic Imaging and Associated Techniques for Diagnosis of Ovarian, Deep Endometriosis, and Adenomyosis: A Comprehensive Review. Semin Reprod Med 2020; 38:216-226. [PMID: 33232986 DOI: 10.1055/s-0040-1718740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Imaging of endometriosis and in particular deep endometriosis (DE) is crucial in the clinical management of women facing this debilitating condition. Transvaginal sonography (TVS) is the first-line imaging method and magnetic resonance imaging (MRI) may provide supplemental information. However, the delay in diagnosis of up to 10 years and more is of concern. This problem might be overcome by simple steps using imaging with emphasis on TVS and referral to tertiary care. Finally, TVS is crucial in mapping extent and location of disease in planning surgical therapy and counseling women regarding various therapeutic options. This review presents the available data on imaging of endometriosis with a focus on TVS and MRI for DE, adenomyosis, and ovarian endometriomas including endometriomas in pregnancy as well as the use of "soft markers." The review presents an approach that is in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement.
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Affiliation(s)
- Mee Kristine Aas-Eng
- Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eliana Montanari
- Department of Gynecology, Certified Center for Endometriosis and Pelvic Pain, Hospital St. John of God, Vienna, Austria.,Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Marit Lieng
- Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Joerg Keckstein
- Stiftung Endometrioseforschung/Endometriosis Research Group Central Europe
| | - Gernot Hudelist
- Department of Gynecology, Certified Center for Endometriosis and Pelvic Pain, Hospital St. John of God, Vienna, Austria.,Stiftung Endometrioseforschung/Endometriosis Research Group Central Europe
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Aas-Eng MK, Dauser B, Lieng M, Diep LM, Leonardi M, Condous G, Hudelist G. Transvaginal sonography accurately measures lesion-to-anal-verge distance in women with deep endometriosis of the rectosigmoid. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:766-772. [PMID: 32068921 DOI: 10.1002/uog.21995] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/14/2020] [Accepted: 02/09/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES First, to investigate the accuracy of transvaginal sonography (TVS) for presurgical evaluation of the distance between the most caudal part of the endometriotic lesion and the anal verge (lesion-to-anal-verge distance (LAVD)) in women with rectosigmoid deep endometriosis (DE), compared with intraoperative measurement (IOM). Second, to assess the agreement between anastomosis height and LAVD measured using TVS. METHODS This was a prospective observational multicenter study of symptomatic women who were scheduled for surgical treatment of rectosigmoid DE, by either discoid or segmental resection, between April 2017 and September 2019. Presurgical TVS was performed to evaluate the LAVD in two ways, depending on the level of the lesion. Method 1: for lesions at the level of the rectovaginal septum (RVS), the caudal part of the lesion was identified on TVS and an index finger was placed on the TVS probe at the level of the anal verge. The probe was withdrawn and the distance from the tip of the TVS probe down to the index finger was measured using a ruler, representing the LAVD. Method 2: for lesions above the RVS, the distance between the caudal part of the lesion and the lower lip of the posterior cervix was measured in a frozen image (LAVD-1), and the distance between the lower lip of the posterior cervix and the anal verge (LAVD-2) was measured using Method 1. These two measurements (LAVD-1 and LAVD-2) were added together and the result represented the total LAVD. During surgery, a rectal probe was used to perform IOM of LAVD, which was considered as the gold standard test. Agreement between LAVD measured using TVS and the IOM was assessed using Bland-Altman analysis. The intraclass correlation coefficient (ICC) for absolute agreement and Spearman's correlation coefficient were also calculated. Systematic and proportional bias were tested for significance using the paired t-test. Similar analysis was performed to assess agreement between LAVD measured using TVS and anastomosis height. RESULTS A total of 147 consecutive women were considered eligible for inclusion. Fourteen women were excluded initially. Thirty-four discoid resections and 102 segmental resections were performed; both procedures were performed in three women. Two more women were excluded from the final analysis because the measurements represented extreme outliers. The mean LAVD measured using TVS was 114.8 ± 36.5 mm and the mean IOM was 116.9 ± 42.3 mm. There was no statistically significant difference between LAVD measured using TVS and IOM (mean difference, -2.12 mm (95% CI, -6.33 to 2.05 mm); P = 0.32). Bland-Altman analysis showed that there was good agreement between the two methods. The ICC was 0.81 (95% CI, 0.74-0.86) and Spearman's correlation coefficient was 0.68 (95% CI, 0.56-0.77). The mean difference between LAVD measured using TVS and anastomosis height was statistically, but not clinically, significant (mean difference, 10.25 mm (95% CI, 5.94-14.32 mm); P = 0.0005), and the ICC was 0.78 (95% CI, 0.66-0.85). CONCLUSIONS There is good agreement between the LAVD measured using TVS and the IOM in women with rectosigmoid DE. As a consequence, TVS could be useful for estimation of the height of the final surgical anastomosis in women undergoing full-thickness resection for rectosigmoid DE. This is of pivotal importance in reducing the risk of complications and need for a temporary stoma, and could improve patient counseling. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M K Aas-Eng
- Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
- Department of Gynaecology, Certified Center for Endometriosis and Pelvic Pain, Hospital St John of God, Vienna, Austria
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - B Dauser
- Department of Surgery, Hospital St John of God, Vienna, Austria
| | - M Lieng
- Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - L M Diep
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - M Leonardi
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School, Nepean Hospital, Sydney, Australia
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School, Nepean Hospital, Sydney, Australia
| | - G Hudelist
- Department of Gynaecology, Certified Center for Endometriosis and Pelvic Pain, Hospital St John of God, Vienna, Austria
- Stiftung Endometrioseforschung/Endometriosis Research Group DACH Region, Central Europe
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Leonardi M, Robledo KP, Espada M, Vanza K, Condous G. SonoPODography: A new diagnostic technique for visualizing superficial endometriosis. Eur J Obstet Gynecol Reprod Biol 2020; 254:124-131. [PMID: 32961428 DOI: 10.1016/j.ejogrb.2020.08.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- M Leonardi
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747, Australia; The University of Sydney Nepean Clinical School, Sydney, 2747, Australia; Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.
| | - K P Robledo
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - M Espada
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747, Australia; The University of Sydney Nepean Clinical School, Sydney, 2747, Australia
| | - K Vanza
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747, Australia; The University of Sydney Nepean Clinical School, Sydney, 2747, Australia
| | - G Condous
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747, Australia; The University of Sydney Nepean Clinical School, Sydney, 2747, Australia; OMNI Ultrasound & Gynaecological Care, St Leonards, Australia
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