Diagnostic accuracy of magnetic resonance imaging, transvaginal, and transrectal ultrasonography in deep infiltrating endometriosis

Lower endoscopic ultrasound in preoperative evaluation of rectosigmoid endometriosis

Background and study aims  Endometriosis affects a significant proportion of reproductive-aged women and involves the bowel in up to one-third of patients with the condition. Lower endoscopic ultrasound (LEUS) in assessment of endometriosis of the rectosigmoid colon was first described 20 years ago in European populations. The current study aimed to describe the diagnostic characteristics of this imaging modality at a tertiary US referral center in a large cohort and its impact on surgical planning. Patients and methods  This was a retrospective cohort study of adult women evaluated for rectosigmoid endometriosis by LEUS at an American tertiary referral center between January 2003 through June 2017. The reference standard for rectosigmoid endometriosis was surgical evaluation regardless of whether tissue was obtained for histologic evaluation. Two separate analyses were run; one comparing EUS to laparoscopic findings and another comparing EUS to histologic findings. Results  LEUS demonstrated a positive predictive value (PPV) of 93.8 % (CI:68.1,99.1) and negative predictive value (NPV) of 96.4 % (CI:87.8,99.0) in the diagnosis of rectosigmoid endometriosis. Test sensitivity was 88.2 % (CI:63.6,98.5) and specificity was 98.2 % (CI:90.1,99.9). Overall diagnostic accuracy of the test was 95.8 % (CI:88.1,99.1). Conclusions  In this large cohort of women at an American tertiary referral center undergoing evaluation for rectosigmoid endometriosis, LEUS demonstrated high PPV and NPV as well as excellent diagnostic accuracy. In addition, the LEUS findings provided important information to the referring gynecologic surgeon. This minimally-invasive imaging modality should be utilized in preoperative evaluation of women undergoing surgery for suspected or known endometriosis.

Transvaginal/transrectal ultrasound-guided aspiration biopsy for diagnosis of pelvic/pelvic floor tumors in females: A retrospective analysis

Ultrasound guidance for histological diagnosis is in real-time, convenient, and economical. The aim of this study was to determine whether transvaginal ultrasound (TVUS)- and transrectal ultrasound (TRUS)-guided aspiration biopsy allows detection of a malignant pathology of pelvic/pelvic masses. Data of 40 patients with pelvic and pelvic mass lesions by computed tomography or magnetic resonance imaging underwent TVUS- or TRUS-guided biopsy. Tissue samples obtained were assessed on suitability for histopathologic evaluation. The post-biopsy complication was monitored. All the specimens in the pelvic floor, vaginal stump, vaginal fornix, cervix, and posterior wall of the anal canal were adequate for histologic diagnosis. There were no post-biopsy complications. Transvaginal/transrectal ultrasound-guided aspiration biopsy is safe and simple. It can be used for the diagnosis and differential diagnosis of pelvic and pelvic floor lesions in women. Prospective studies are needed to test diagnostic performance across clinical scenarios.

Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: Systematic review and meta-analysis

INTRODUCTION

Intestinal endometriosis is considered the most severe form of deep endometriosis, the rectosigmoid being involved in about 90% of cases of bowel infiltration. Transvaginal sonography (TVS) and magnetic resonance imaging (MRI) have been used for noninvasive diagnosis and preoperative mapping of rectosigmoid endometriosis (RE), but no consensus has been reached so far regarding which method is the most accurate in this setting.

OBJECTIVE

We aimed at performing a systematic review and meta-analysis to compare the accuracy of TVS versus MRI in the diagnosis of RE in a same population.

METHODS

A systematic review was conducted in accordance with the PRISMA guidelines. Studies were identified by searching the MEDLINE, Embase, and LILACS databases, as well the reference lists of retrieved articles, through February 2019. We included all cross-sectional studies that evaluated the accuracy of TVS versus MRI in the diagnosis of RE within a same sample of subjects and that used surgical findings with histological confirmation as the gold standard. The QUADAS-2 instrument was used to evaluate study quality. Sensitivity, specificity, positive likelihood ratios (LR+), and negative likelihood ratios (LR-) for the diagnosis of RE were calculated. This study is registered with PROSPERO, number CRD42017064378.

RESULTS

Eight studies (n = 1132) were included in the meta-analysis. The pooled sensitivity, specificity, LR+, and LR- values of MRI for RE were 90% (95% CI, 87-92%), 96% (95% CI, 94-97%), 17.26 (95% CI, 3.57-83.50), and 0.15 (95% CI, 0.10-0.23); values of TVS were 90% [95% CI, 87-92%], 96% (95% CI, 94-97%), 20.66 (95% CI, 8.71-49.00) and 0.12 (95% CI, 0.08-0.20), respectively. Areas under the S-ROC curves (AUC) showed no statistically significant differences between MRI (AUC = 0.948) and TVS (AUC = 0.930) in the diagnosis of RE (P = 0.13). Moreover, considering the average prevalence among the studies of 47.3%, both methods demonstrated similarly high positive post-test probabilities (93.9% for TVS and 94.8% for MRI), and the combined use of them yielded a post-test probability of 99.6%.

CONCLUSION

MRI and TVS have similarly high accuracy and positive post-test probabilities in the noninvasive diagnosis of RE. Combination of MRI and TVS may increase even further the positive post-test probabilities to near 100%.

Preoperative rectosigmoid endoscopic ultrasonography predicts the need for bowel resection in endometriosis

BACKGROUND

Rectosigmoid endometriosis is an underdiagnosed disease responsible for abdominal pain, transit disorders and rectal bleeding. Two surgical approaches, rectosigmoid bowel resection (segmental or patch) or intramuscular layer dissection (shaving), are available.

AIM

To assess whether the lesion features observed via preoperative rectosigmoid endoscopic ultrasonography (RS-EUS) might predict the need for bowel resection.

METHODS

This multicentric retrospective study was conducted on patients with rectosigmoid endometriosis who underwent a curative surgical procedure, evaluated by RS-EUS performed by two trained operators, between January 2012 and March 2018. A univariate statistical analysis was performed on nodules’ RS-EUS features (thickness, width, infiltration of the submucosae, presence of a bump into the digestive lumen and presence of multiple rectosigmoid localizations). A multivariate logistic regression was then performed on the significant results.

RESULTS

Of the 367 patients, 73 patients with rectosigmoid endometriosis were evaluated by RS-EUS and underwent rectosigmoid surgery. After the univariate analysis was completed, thickness, width and infiltration of the submucosae were identified as potential predictive factors for bowel resection. In a multivariate logistic regression model, only thickness appeared to be a significant [odds ratio (OR) = 1.49, 95% confidence interval (CI): 1.04-2.12, P = 0.028] predictive factor for bowel resection. Receiver operating characteristic analysis performed showed that a thickness over 5.20 mm might be used as cut-off with a sensitivity of 76%, a specificity of 81%, and an area under carve = 0.82. The cut-off values for 100% sensitivity and 100% specificity were 0.90 mm and 10.00 mm, respectively. A trend concerning width to predict the need for resection was also observed (OR 1.12, 95%CI: 1.00-1.26, P = 0.054)

CONCLUSION

The presence of a rectosigmoid nodule of endometriosis greater than 5.20 mm thick on RS-EUS might predict the need for bowel resection.