Bladder endometriosis: Preoperative MRI analysis with assessment of extension to ureteral orifices

Percutaneous cryoablation of abdominal wall endometriosis: An analysis of 38 patients

PURPOSE

The purpose of this study was to evaluate the efficacy of percutaneous cryoablation in the treatment of abdominal wall endometriosis (AWE) nodules.

MATERIALS AND METHODS

Thirty-eight women treated for symptomatic AWE nodules with percutaneous cryoablation under ultrasound and computed tomography (CT) guidance between May 2020 and July 2023 were retrospectively included. Pain was estimated using visual analog scale (VAS) and assessed at baseline, three months, six months, and 12 months after percutaneous cryoablation. Baseline VAS score, volume of AWE nodule and magnetic resonance imaging (MRI) features of AWE nodules were compared to those obtained after percutaneous cryoablation. Major complications, if any, were noted.

RESULTS

Thirty-eight women with a median age of 35.5 years (interquartile range [IQR]: 32, 39; range: 24-48 years) and a total of 60 AWE nodules were treated. Percutaneous cryoablation was performed under local or regional anesthesia in 30 women (30/38; 79%). Significant decreases between initial median VAS score (7; IQR: 6, 8; range: 3-10) and median VAS score after treatment at three months (0; IQR: 0, 5; range; 0-8) (P < 0.001), six months (0; IQR: 0, 1; range; 0-10) (P < 0.001) and 12 months (0; IQR: 0, 2; range: 0-7) (P < 0.001) were observed. Percutaneous cryoablation resulted in effective pain relief in 31 out of 38 women (82%) at six months and 15 out of 18 women (83%) at 12 months. Contrast-enhanced MRI at six-month follow-up showed a significant decrease in the volume of AWE nodules and the absence of AWE nodule enhancement after treatment by comparison with baseline MRI (P < 0.001). No major complications were reported.

CONCLUSION

Percutaneous cryoablation is an effective, minimally invasive intervention for the treatment of AWE nodules that conveys minimal or no morbidity.

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.

Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique

Endometriosis is a chronic inflammatory gynecological condition affecting 10-15% of women in the reproductive age group. The urinary tract is the second most common extragenital organ system affected by endometriosis, and the urinary bladder and ureter are the two most common sites involved. Involvement of the urinary bladder can cause chronic debilitating symptoms, whereas ureteral involvement may lead to asymptomatic loss of renal function. Both conditions are frequently unsuspected, leading to a delay in diagnosis. Therefore, it is important to recognize this entity early, for which knowledge of imaging appearances and techniques is helpful. In this review article, we describe (a) endometriosis background, pathogenesis, definitions and clinical symptoms, (b) imaging appearance, with emphasis on ultrasound and MRI findings of urinary bladder and ureteric endometriosis, (c) ultrasound technique and MRI sequences useful for making the correct diagnosis, (d) overview of the treatment options and key imaging findings that are important to the surgeon for surgical planning, and (e) a structured reporting template useful for multidisciplinary patient management.

Urological knowledge and tools applied to diagnosis and surgery in deep infiltrating endometriosis - a narrative review

OBJECTIVES

This review discusses deep infiltrating endometriosis (DIE) diagnosis and surgery using current urological knowledge and technologies.

MATERIALS AND METHODS

Narrative review of deep infiltrating endometriosis that result in urological issues. We examined manuscripts from Pubmed, Embase, and Scielo's database using the following MeSH terms: ('endometriosis') AND ('urology' OR 'urological' OR 'urologist') AND ('bladder' OR'vesical') AND ('ureteral' OR 'ureter').Selection followed PRISMA guidelines. Sample images from our records were brought to endorse the findings.

RESULTS

Thirty four related articles were chosen from 105. DIE may affect the urinary system in 52.6% of patients. Lower urinary tract symptoms may require urodynamic examination. Ultrasonography offers strong statistical yields for detecting urinary tract lesions or distortions, but magnetic resonance will confirm the diagnosis. Cystoscopy can detect active lesions, although any macroscopic visual appeal is pathognomonic. Endourology is utilized intraoperatively for bladder and ureteral assessment, however transurethral endoscopic excision of bladder lesions had higher recurrence rates. Laparoscopy is the route of choice for treatment; partial cystectomy, and bladder shaving were the most prevalent surgical treatments for bladder endometriosis. Regarding the ureteral treatment, the simple ureterolysis and complex reconstructive techniques were described in most papers. Using anatomical landmarks or neuronavigation, pelvic surgical systematization allows intraoperative neural structure identification.

CONCLUSIONS

DIE in the urinary system is common, however the number of publications with high level of evidence is limited. The initial tools for diagnosis are ultrasonography and cystoscopy, but magnetic resonance is the most reliable tool. When the patient has voiding symptoms, the urodynamic examination is crucial. Laparoscopy improves lesion detection and anatomical understanding. This approach must be carried out by professionals with high expertise, since the surgery goes beyond the resection of lesions and includes the preservation of nerve structures and urinary tract reconstruction techniques.

Comparison between CT-enterography and MR-enterography for the diagnosis of right-sided deep infiltrating endometriosis of the bowel

OBJECTIVE

To compare computed tomography-enterography (CTE) and magnetic resonance-enterography (MRE) in the detection of right-sided bowel deep infiltrating endometriosis (DIE).

MATERIALS AND METHODS

Fifty women with DIE who underwent preoperatively CTE and MRE were included. CTE and MRE were first analyzed separately by two independent readers who analyzed five bowel segments (cecum, appendix, ileocecal junction, distal ileum and proximal small bowel [i.e., proximal ileum and jejunum]) for the presence of DIE and then interpreted in consensus. CTE, MRE and CTE with MRE were compared in terms of sensitivity, specificity and accuracy. Interobserver agreement was assessed with kappa (κ) test.

RESULTS

Using the reference standard 25 out 250 bowel segments were involved by DIE in 18 women and 225 were free of DIE. Sensitivity, specificity, and accuracy of CTE were 60% (95% confidence interval [CI]: 39-79), 93% (95% CI: 89-96) and 90% (95% CI: 85-93) for Reader 1, respectively, and 52% (95% CI: 31-72), 99% (95% CI: 97-100) and 94% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.564) and specificity (P = 0.181) between readers and fair interobserver agreement (κ = 0.37). For MRE these figures were 52% (95% CI: 31-72), 92% (95% CI: 88-95) and 88% (95% CI: 84-92) for Reader 1 and 60% (95% CI: 39-79), 99% (95% CI: 96-100) and 95% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.157) and specificity (P = 0.061) between readers and fair interobserver agreement (κ = 0.31). Significant differences in sensitivity (20%; 95% CI: 7-41) were found between CTE + MRE vs. CTE alone for Reader 1 and vs. MRE alone for Reader 2 (P = 0.041 for both) CONCLUSION: CTE and MRE have not different sensitivities and convey only fair interobserver agreement but are highly specific for the diagnosis of right-sided bowel DIE. CTE and MRE are complementary because they improve the detection of DIE implants when used in combination.

Deep pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group

PURPOSE

The purpose of this consensus article was to develop guidelines by a focused panel of experts to elaborate a lexicon of image interpretation, and a standardized region-based reporting of deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Evidence-based data and expert opinion were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of pelvic compartment delineation and reporting template were collected; responses were analyzed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS

Consensus regarding pelvic compartment delineation and DIE reporting was attained using the RAND-UCLA Appropriateness Method. The pelvis was divided in nine compartments and extrapelvic lesions were assigned to an additional (tenth) compartment. A consensus was also reached for each structure attributed to a compartment and each reporting template item among the experts. No consensus was reached for a normal aspect of uterosacral ligament, but a consensus was reached for an unequivocal involvement leading to a positive diagnosis and an equivocal involvement leading to uncertain diagnosis. Tailored MRI lexicon and standardized region-based report were proposed.

CONCLUSION

These consensus recommendations should be used as a guide for DIE reporting and staging with MRI. Standardized MRI compartment-based structured reporting is recommended to enable consistent accuracy and help select the best therapeutic approach.

Transvaginal Ultrasound vs. Magnetic Resonance Imaging (MRI) Value in Endometriosis Diagnosis

(1) Background: Endometriosis is a widespread gynecological condition that causes chronic pelvic discomfort, dysmenorrhea, infertility, and impaired quality of life in women of reproductive age. Clinical examination, transvaginal ultrasonography (TVS), and magnetic resonance imaging (MRI) are significant preoperative non-invasive diagnosis procedures for the accurate assessment of endometriosis. Although TVS is used as the primary line for diagnosis, MRI is commonly utilized to achieve a better anatomical overview of the entire pelvic organs. The aim of this systematic review article is to thoroughly summarize the research on various endometriosis diagnosis methods that are less invasive. (2) Methods: To find relevant studies, we examined electronic databases, such as MEDLINE/PubMed, Cochrane, and Google Scholar, choosing 70 papers as references. (3) Results: The findings indicate that various approaches can contribute to diagnosis in different ways, depending on the type of endometriosis. For patients suspected of having deep pelvic endometriosis, transvaginal sonography should be the first line of diagnosis. Endometriosis cysts are better diagnosed with TVS, whereas torus, uterosacral ligaments, intestine, and bladder endometriosis lesions are best diagnosed using MRI. When it comes to detecting intestine or rectal nodules, as well as rectovaginal septum nodules, MRI should be the imaging tool of choice. (4) Conclusions: When diagnosing DE (deep infiltrative endometriosis), the examiner’s experience is the most important criterion to consider. In the diagnosis of endometriosis, expert-guided TVS is more accurate than routine pelvic ultrasound, especially in the deep infiltrative form. For optimal treatment and surgical planning, accurate preoperative deep infiltrative endometriosis diagnosis is essential, especially because it requires a multidisciplinary approach.

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.