Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

Prevalence of adenomyosis features in women scheduled for assisted reproductive treatment, using the Morphological Uterus Sonographic Assessment group definitions

INTRODUCTION

Studies that use standardized ultrasonographic criteria to diagnose adenomyosis in subfertile women are needed. These would improve the understanding of the disease burden and enable further studies on its impact on fertility and assisted reproductive treatment (ART) outcome. The aim of this study was to determine the prevalence of different features of adenomyosis in women scheduled for their first ART, diagnosed at two (2D) and three-dimensional (3D) transvaginal ultrasonography (TVUS) using the revised Morphological Uterus Sonographic Assessment (MUSA) group definitions.

MATERIAL AND METHODS

This was a prospective, observational cross-sectional study of subfertile women aged 25 to ≤39 years, that were referred to a university hospital for their first ART between December 2018 and May 2021. Of 1224 eligible women, 1160 women fulfilled the inclusion criteria and consented to participate in the study. All women underwent a systematic 2D and 3D TVUS examination. The primary outcome was the presence of direct and indirect features of adenomyosis, as proposed by the MUSA group. Secondary outcomes were to describe the ultrasonographic characteristics of the different features, as well as any difference in the diagnostics at 2D or 3D TVUS and any association with clinical characteristics such as endometriosis.

RESULTS

At least one direct or indirect feature of adenomyosis was observed in 272 (23.4%, 95% confidence interval [CI] 21.0-25.9) women. Direct features that are pathognomonic for the disease were observed in 111 (9.6%, 95% CI, 7.9-11.3) women. Direct features were visible only at 3D TVUS in 56 (4.8%, 95% CI 3.6-6.1) women, that is, 56/111 (50.5%) of women with at least one direct adenomyosis feature. Direct features were more common in women with endometriosis (OR 2.8, 95% CI 1.8-4.3).

CONCLUSIONS

We found than one in 10 women scheduled for ART had direct features of adenomyosis at ultrasound examination. The present study suggests that the use of 3D TVUS is an important complement to 2D in the diagnostics of adenomyosis. Our results may further improve the counseling of women scheduled for ART and enables future studies on the impact of different features of adenomyosis on subfertility, ART results and obstetric outcomes.

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.

Atypical Endometriosis: A Comprehensive Systematic Review of Pathological Patterns and Diagnostic Challenges

Endometriosis is a benign condition affecting women of reproductive age. A potential association with ovarian cancer has been documented. Atypical endometriosis (AE) is characterized by deviations from the typical microscopic appearance of endometriosis, including cytologic and architectural atypia. AE has been recognized as a potential precursor to endometriosis-associated ovarian cancers (EAOC), particularly endometrioid and clear cell subtypes. AE presents challenges in diagnosis due to its diverse clinical and pathological features, often requiring careful histological evaluation for accurate identification. Architectural AE, defined by localized proliferation of crowded glands with atypical epithelium resembling endometrial neoplasia, and cytologic AE, characterized by nuclear atypia within the epithelial lining of endometriotic cysts, are key subtypes. Immunohistochemical and molecular studies have revealed aberrant expression of markers such as Ki67, COX-2, BAF250a, p53, estrogen receptor, progesterone receptor, and IMP-3. Long-term follow-up studies suggest relatively low recurrence and malignant transformation rates among patients with AE, but uncertainties persist regarding its exact malignancy potential and optimal management strategies. Integration of artificial intelligence and shared molecular aberrations between AE and EAOC may enhance diagnostic accuracy. Continuous interdisciplinary collaboration and ongoing research efforts are crucial for a deeper understanding of the relationship between endometriosis and carcinogenesis, ultimately improving patient care and surveillance.

Development of deep pelvic endometriosis following acute haemoperitoneum: a prospective ultrasound study

STUDY QUESTION

Is acute haemoperitoneum that is managed conservatively a precursor of deep endometriosis?

SUMMARY ANSWER

Our study provides evidence to suggest that acute haemoperitoneum may lead to the development of deep endometriosis in a significant proportion of cases.

WHAT IS KNOWN ALREADY

A recent pilot study was the first to suggest that acute haemoperitoneum could be a precursor of deep endometriosis. However, the sample size was small, and the follow-up was not standardized owing to unknown rates of clot absorption and development of endometriosis.

STUDY DESIGN SIZE DURATION

This was a prospective observational cohort study conducted at a single centre over a 31-month period. A required sample size of 30 was calculated using results from a previous study, with a minimum of 15 women each in the groups with and without significant haemoperitoneum (study and control groups, respectively). A total of 59 women were recruited to the study and eight were lost to follow-up. The final sample comprised 51 women, 15 in the study group and 36 in the control group.

PARTICIPANTS/MATERIALS SETTING METHODS

All non-pregnant, premenopausal women aged 18-50 years who consecutively presented to our dedicated gynaecological diagnostic unit with severe acute lower abdominal pain were eligible for this study. We only included women who were clinically stable and were suitable for conservative management. Those with prior history or evidence of endometriosis on their initial ultrasound scan, previous hysterectomy, or bilateral oophorectomy were excluded. Participants had standardized follow-up visits for 6 months, with pelvic ultrasound scans and the British Society of Gynaecological Endoscopy pelvic pain questionnaires completed at each visit. The primary outcome was the sonographically confirmed presence of newly formed endometriosis. Secondary outcomes were the presence and change of pelvic pain symptoms and health-related quality of life (HR-QOL).

MAIN RESULTS AND THE ROLE OF CHANCE

After completion of follow-up, 7/15 (47%; 95% CI 21.3-71.4%) women presenting with acute haemoperitoneum (study group) developed sonographic evidence of deep endometriosis, compared to 0/36 (0%; 97.5% CI 0.0-9.7%) women in the control group. A ruptured functional haemorrhagic cyst was the most common cause of haemoperitoneum, occurring in 13/15 cases (87%). The time from the initial event to sonographic evidence of endometriosis varied from 2 to 6 months. The EuroQol visual analogue scores were not significantly different at baseline between the groups that developed and did not develop endometriosis [28 (interquartile range (IQR) 15-40, n = 6) vs 56 (IQR 35-75, n = 44), P = 0.09], while the EuroQol-5D values were lower in the endometriosis group [-0.01 (IQR -0.07 to 0.19, n = 6) vs 0.62 (IQR 0.24-0.73, n = 44), P = 0.002]. At 6 months, the EuroQol-5D scores were improved in both groups, but remained significantly lower in the endometriosis group compared to the no endometriosis group [0.69 (IQR 0.66-0.80, n = 6) vs 0.85 (IQR 0.76-1.00, n = 44), P = 0.03]. There was no clinically relevant difference in the pelvic pain scores at either time point.

LIMITATIONS REASONS FOR CAUTION

It remains uncertain whether minimal, superficial endometriosis existed at commencement of the study and had a role in the development of deep endometriosis. Although the ultrasound findings were in keeping with deep endometriosis, this was not confirmed histologically. The pelvic pain and HR-QOL findings could have been influenced by the baseline scores being taken when the patient was admitted with acute pain. Also, the sample size was too small to draw reliable conclusions regarding the impact of newly developed endometriosis on QoL.

WIDER IMPLICATIONS OF THE FINDINGS

Our study provides further evidence showing that significant haemoperitoneum may be a precursor of deep endometriosis. Haemodynamically stable women presenting with acute pelvic pain and significant haemoperitoneum should be counselled about the risk of developing deep endometriosis. Interventional studies should be carried out in the future to see whether laparoscopy and pelvic washout could prevent development of deep endometriosis. Preventative strategies, including treatment to suppress ovulation and formation of functional cysts, should be further investigated. This includes the combined and progesterone-only contraceptive pills. Larger future studies are also required to assess women over a longer period of time, with adjustment for confounding factors, to evaluate a possible effect on HR-QOL and pain symptoms.

STUDY FUNDING/COMPETING INTERESTS

Funding was obtained from The Gynaecology Ultrasound Centre, London, UK. TT received personal fees from GE, Samsung, Medtronic, and Merck for lectures on ultrasound. TT also received a postdoctoral grant from the South-Eastern Norwegian Health Authority (grant number 2020083).

TRIAL REGISTRATION NUMBER

researchregistry6472.

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.

Adenomyosis diagnosis among adolescents and young women with dysmenorrhoea and heavy menstrual bleeding

RESEARCH QUESTION

What is the prevalence of adenomyosis at ultrasonography among adolescents and young women reporting dysmenorrhoea and/or heavy menstrual bleeding (HMB)?

DESIGN

This observational cohort study involved adolescents and young women referred for dysmenorrhoea and/or HMB to the Adolescent Medicine Unit at Careggi University Hospital, Italy. Patients with endometriosis and bleeding disorders were excluded. Transvaginal ultrasonography or transrectal sonography using a transvaginal probe was performed. The myometrium was described according to the Morphological Uterus Sonographic Assessment criteria. Details of baseline characteristics, clinical data and symptoms were collected. The presence of sonographic features of adenomyosis and the association between imaging findings and clinical symptoms were evaluated.

RESULTS

The cohort included 95 patients aged between 13 and 25 years, referred for dysmenorrhoea (88.4%), HMB (23.2%) or both (13.7%). According to the MUSA criteria the sonographic diagnosis of adenomyosis was made in 27.4% of patients, with the diffuse type the most prevalent. Uterine wall asymmetry, hyperechoic intramyometrial islands, translesional vascularity and an interrupted junctional zone were the most common features. Patients with imaging findings of adenomyosis had significantly higher rates of HMB than those with a normal myometrial appearance (38.5% versus 17.4%, P = 0.030). In addition, the coexistence of dysmenorrhoea and HMB was significantly associated with adenomyosis (odds ratio 5.68, 95% confidence interval 1.65-19.5).

CONCLUSIONS

Adenomyosis may be diagnosed among teenagers and young women referred with dysmenorrhoea and/or HMB. The clinical presentation is relevant for the diagnosis, with HMB alone and HMB plus dysmenorrhoea significantly associated with the sonographic identification of adenomyosis.

Endometriosis diagnosed by ultrasound is associated with lower live birth rates in women undergoing their first in vitro fertilization/intracytoplasmic sperm injection treatment

OBJECTIVE

To study the cumulative live birth rate (CLBR) after the first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment in women with or without deep-infiltrating endometriosis (DIE) and/or endometrioma diagnosed by transvaginal ultrasonography (TVUS), using the International Deep Endometriosis Analysis (IDEA) group definitions.

DESIGN

Prospective observational cohort study at a university hospital.

PATIENTS(S)

In total, 1,040 women with subfertility aged 25 to ≤39 years were undergoing their first IVF/ICSI treatment between January 2019 and October 2022. Of these, 234 (22.5%; 95% confidence interval [CI], 20.0-25.0) women were diagnosed with DIE and/or endometrioma at systematic TVUS before starting their treatment.

INTERVENTION(S)

All women underwent their first IVF or ICSI treatment. Fresh and/or frozen embryos from the first cycle were used until pregnancy was achieved or no embryos remained.

MAIN OUTCOME MEASURE(S)

Cumulative live birth rate after the first IVF/ICSI cycle in women with or without DIE and/or endometrioma.

RESULT(S)

The CLBR after the first IVF/ICSI treatment in the total cohort of women was 426/1,040 (41.0%; 95% CI, 38.0-44.0). Women with DIE and/or endometrioma had a lower CLBR (78/234, 33.3%; 95% CI, 27.3-39.4) than women without the disease (348/806, 43.2%; 95% CI, 39.8-46.6). The crude relative risk (RR) for cumulative live birth for women with DIE and/or endometrioma was 0.77; 95% CI, 0.63-0.94, and after adjustments were made for age, body mass index, s-antimüllerian hormone, stimulation protocol, and day for embryo transfer, the adjusted RR was 0.63; 95% CI, 0.48-0.82. There was no difference in the number of retrieved mature oocytes, fertilization rate, or good quality embryos between the 2 groups.

CONCLUSION

The presence of DIE and/or endometrioma diagnosed by TVUS lowers the chance of live birth in women undergoing their first IVF/ICSI treatment.

Correlation Between Surgical Phenotype and Pain Improvement After Endometriosis Surgery

STUDY OBJECTIVE

To examine pain improvement after endometriosis surgery and whether it can be predicted by the observed surgical phenotype.

DESIGN

Prospective longitudinal survey study.

SETTING

A University hospital.

PATIENTS

A total of 125 patients completed a preoperative questionnaire (response rate: n = 227 of 277, 81.9%), had surgically confirmed endometriosis (n = 202 of 227), and returned a second postoperative questionnaire (response rate: n = 125 of 202, 61.9%).

INTERVENTIONS

All patients underwent complete laparoscopic removal of the endometriotic lesions. Surgical phenotype was classified according to the rASRM and #Enzian classification.

MEASUREMENTS AND MAIN RESULTS

The intensity of 5 specific pain symptoms was questioned by postal paper-pencil questionnaires with a numerical rating scale (0-10) both preoperatively (3.01 ± 2.72 months before surgery) and one year after surgery (12.62 ± 1.59 months). A postoperative pain improvement score was computed (postoperative pain-preoperative pain) for each specific pain symptom (0-10) and for the overall/global pain sum score (0-50). The mean intensity of all pain scores was lower postoperatively as compared with preoperatively (p <.0001). A statistically significant weak correlation was observed between the surgical phenotype "rectovaginal endometriosis" and postoperative improvement of dyspareunia (r = .265; p = .003). The other 11 hypothesized correlations between surgical phenotype and postoperative improvement of pain intensity failed to reach statistical significance.

CONCLUSION

Clinicians can inform patients that surgery is effective in reducing endometriosis-related pain symptoms and the overall/global pain scores at 12 months postoperatively. From our data, we can conclude that patients with rectovaginal endometriosis might benefit the most from the reduction of their sexual pain. On the basis of these results, we could suggest that deep dyspareunia (even if present as an isolated symptom) might be a valid indication for surgery. Further research could explore the association between a certain surgical phenotype and more detailed assessments of sexual functioning, as well as explore whether feedback from the surgeon on expected pain improvement affects patient-reported outcomes.

The correlation between ultrasonographic findings and clinical symptoms of pelvic endometriosis

OBJECTIVE

Considering the importance of endometriosis and its relatively high prevalence among women, this study sought to investigate clinical and Transrectal and transvaginal ultrasounds (TVS) findings of disease.

METHODS

This descriptive-analytical study was performed based on medical records of 155 women with endometriosis admitted to Rasool-e Akram Hospital in Tehran for a TVS. All the sonography data and patients' information were collected into checklists and analyzed in SPSS-25 software (IBM).

RESULTS

The mean age of participants was 32.4 ± 6.1 years, ranging from 18 to 50 years. Endometrioma was prevalent in 129 patients (84.8%). Size of endometrioma (diameter) was more than 3 cm in 79.9% of patients, and 3 cm or fewer in 20.1% of cases. Bladder, intestinal, vaginal, and rectosigmoid involvements with endometriosis implants were observed in 4 (2.6%), 54 (35.5), 3 (0.2%), and 51 (33.5) of patients, respectively. A total of 64.5% of patients were diagnosed with incomplete stenosis of the Douglas pouch and 35.5% had complete stenosis. Deep infiltrating endometriosis (DIE) was less than 1 cm in 20.7%, 1 to 3 cm in 42.3%, and over 3 cm in 37% of patients. The most common manifestations of endometriosis Obliteration of the Douglas pouch, endometrioma, and DIE. In addition, imaging modalities have shown promising results, indicating the necessity to use transvaginal ultrasound as the first line of diagnosis in patients with clinically suspected endometriosis.

Breast Cancer in Patients with Previous Endometriosis Showed Low Aggressive Subtype

Background and Objectives: The association between endometriosis and breast cancer still remains controversial. The aim of this study was to investigate the different subtypes of breast cancer, immunohistochemical markers, hormone receptors, and ki67 proliferation indexes in patients with and without endometriosis and/or adenomyosis. Materials and Methods: All patients with endometriosis and breast cancer were enrolled. Women with endometriosis and breast cancer (Group BC+EN+) were compared to patients with breast cancer without endometriosis (group BC+EN-) and those with endometriosis without breast cancer (group BC-EN+). General population characteristics and histological and immunohistochemical subtypes of breast cancer were compared between groups. Results: Our study included 41 cases affected by both endometriosis and/or adenomyosis and breast cancer (Group BC+EN+) that were matched (1:2) with 82 patients affected only by breast cancer (group BC+EN-) and 82 patients affected only by endometriosis and/or adenomyosis (group BC-EN+). Group BC+EN+ presented a higher percentage of ER receptor expression (83% vs. 70%, p = 0.02), as well as lower values of Ki 67% (15% vs. 24%, p < 0.0001) and HER2+ (9.8% vs. 28%, p = 0.022). These findings were more evident when comparing patients with premenopausal status, while in postmenopausal patients, this difference was no longer significant. Regarding endometriosis, no statistical differences were observed in type or specific localization of the disease among the groups with and without breast cancer. Conclusions: Patients with endometriosis presented lower aggressive breast cancer rates with higher values of ER% and lower values of Ki 67 and HER2neu+. The type and severity of endometriotic diseases seemed not to influence breast cancer occurrence.

Comparison of clinical and ultrasound examinations in assessing the parametria in patients with deep infiltrating endometriosis: a multicentre prospective study

RESEARCH QUESTION

How do clinical rectovaginal examination and transvaginal ultrasound examination perform in the diagnosis of parametrial infiltration in patients with endometriosis?

DESIGN

This was a multicentre prospective observational study. Patients with suspected deep endometriosis at clinical examination and/or at ultrasound evaluation and scheduled for surgery were included. Following multicentre multidisciplinary meetings, consensus was obtained on terms and methodology to define the parametrium at pelvic anatomy, ultrasound and surgery. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios were calculated for clinical and ultrasound examinations with respect to surgery.

RESULTS

In total, 195 women were selected for the present study and 164 were included in the analysis. Ultrasound examination had good to high specificity (>80%) for all parameters, except the left lateral parametrium (78.8%). The sensitivity of ultrasound examination was good to high for fixity of the right and left ovaries, uterosacral ligaments, retrocervix and rectovaginal space; and low for the anterior and lateral parametria, vagina, bladder and bowel. Clinical examination had good to high specificity for fixity of the left ovary, anterior parametrium, right uterosacral ligament, retrocervix and vagina; and low specificity for fixity of the right ovary, lateral parametrium, left uterosacral ligament and rectovaginal space. The sensitivity of clinical examination was good for the uterosacral ligaments and rectovaginal space, and low for the remaining parameters.

CONCLUSION

Ultrasound examination provided good specificity for all the parameters, but sensitivity was low for the anterior and lateral parametria. Clinical examination provided good specificity for the anterior and posterior parametria, but sensitivity was low for the anterior and lateral parametria. Further prospective studies are needed to validate this methodology and confirm the results.

Postoperative Imaging of Endometriosis

Endometriosis is a highly prevalent disease that affects 10%-15% of women of reproductive age worldwide and is mainly associated with chronic pelvic pain and infertility. With the widespread use of imaging for the diagnosis and monitoring of endometriosis, combined with the ability of surgery to eradicate the disease and address infertility, there has been a significant increase in recent years in imaging examinations for postoperative evaluation of endometriosis. US and MRI are used not only to help diagnose and map endometriosis but also to evaluate refractory symptoms, residual lesions, and complications at posttreatment assessment. Knowledge of surgical techniques and recognition of expected postoperative imaging findings are crucial to differentiate postoperative changes from residual disease and/or recurrence. The authors discuss imaging aspects of postoperative endometriosis, with an emphasis on the imaging approach, comprehension of surgical techniques, recognition of the expected findings, possible complications, and analysis of residual disease or recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by VanBuren in this issue. The slide presentation from the RSNA Annual Meeting is available for this article.

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.

KAT2A changes the function of endometrial stromal cells via regulating the succinylation of ENO1

Endometriosis is increasingly affecting women worldwide and research is focusing on identifying key targets in its pathogenesis. Changes in succinylation genes regulate the function of this protein and further influence the development of the disease. However, the role of succinylation genes in endometriosis is not clear from current studies. The expression of succinylation genes was determined in ectopic endometrium (EC) and ectopic patients with uterine fibroids (EN) by real-time quantitative PCR (qRT-PCR) and Western blot. Cell Counting Kit-8, transwell assays, and flow cytometry were used to assess endometrial stromal cells (ESCs) proliferation, apoptosis, migration, and invasion. KAT2A and ENO1 association was detected by qRT-PCR, immunofluorescence, and CoIP. We found that gene and protein levels of KAT2A were significantly increased in the EC group compared to EN group tissues. KAT2A silencing inhibited cell proliferation, migration, and invasion and promoted apoptosis. Western blot results showed that the expression of ENO1 and its succinylation was significantly upregulated in ECSc after KAT2A overexpression. CoIP results showed that KAT2A is positively bound to ENO1. Immunofluorescence also showed co-localized expression of KAT2A with ENO1. Furthermore, ENO1 overexpression reversed the effects of KAT2A silencing on the malignant behavior of ESCs. In summary, we found that succinylation of ENO1 mediated by KAT2A played a role in promoting the progression of endometriosis.

Determination of Serum Arginase-1 Concentrations and Serum Arginase Activity for the Non-Invasive Diagnosis of Endometriosis

Backgroud: Endometriosis remains a diagnostic challenge, both clinically and economically, affecting 6% to 15% of women of child-bearing potential. We have attempted to determine whether testing serum concentrations and activity of arginase isoenzymes could be useful for the non-invasive diagnosis of endometriosis. Methods: This study involved 180 women (105 endometriosis subjects-study group B; 22 subjects with other benign gynaecological conditions-control group 1-K1, both undergoing surgery; and 53 healthy subjects without features of endometriosis-control group 2-K2). Results: Preoperative and postoperative arginase-1 (Arg-1) concentrations were significantly higher in patients, as compared with the control groups K1 (p < 0.0001 and p = 0.0005, respectively) and K2 (both p < 0.0001). Similarly, arginase activity was significantly higher in patients than in the control group K1 before surgery and higher than in both control groups after surgery. No significant differences in either Arg-1 concentrations or arginase activity were noted between the operated control group K1 and the non-operated control group K2. A significant postoperative decrease in Arg-1 concentration was observed within both patient (p < 0.0001) and control group K1 (p = 0.0043). Diagnostic performance was assessed using the receiver operating characteristic (ROC) method. The threshold for differentiation between endometriosis patients and healthy non-operated controls was 42.3 ng/mL, with a sensitivity of 90% and specificity of 81%. For differentiation of patients and operated controls with benign gynaecological conditions, the threshold was 78.4 ng/mL, with a sensitivity of 61% and specificity of 95%. Conclusions: We, therefore, conclude that Arg-1 serum concentrations and arginase activity could be considered potential biomarkers for endometriosis but require further studies on larger cohorts of patients.

An Ultrasound-Based Preoperative Evaluation of the Endometriosis Fertility Index: A Further Step towards Personalized Treatment

Background: The Endometriosis Fertility Index (EFI), is a crucial validated surgical tool used for predicting fertility outcomes in women with endometriosis. This study aims to assess the concordance between a preoperative clinical and instrumental EFI evaluation (uEFI) and the EFI score obtained during an exploratory laparoscopy prior to surgery (sEFI). Methods: This study presents preliminary data from a broader observational cohort study. The Least Function score for the uEFI was calculated using a modified version of the original surgical EFI by incorporating a clinical examination, advanced ultrasound, and hysterosalpingo-foam sonography (HyFoSy). Results: The preoperative estimation of the EFI (uEFI) demonstrated a high concordance (k = 0.695, ρs = 0.811) with the sEFI. Remarkably, the surgical interventions led to a significant improvement in the EFI values, with 80% of the intermediate EFI transitioning to a high level, thereby highlighting the positive impact of surgery on fertility outcomes. Conclusion: This study highlights the accuracy of preoperative EFI estimation (uEFI) and its strong agreement with intraoperative assessment. It underscores the potential of a preoperative management tool to guide the allocation of infertile women with endometriosis to operative laparoscopy, direct assisted reproductive technology (ART), or spontaneous attempts at pregnancy.

Delayed diagnosis and treatment of adolescents and young women with suspected endometriosis

STUDY OBJECTIVE

Early diagnosis and treatment of endometriosis in adolescents and young women is considered essential for improving their quality of life and for prevention of long-term complications. In adult women with endometriosis, significant delays in diagnosis and medical or surgical treatment have been described. Our study aimed to investigate the delay in diagnosis and treatment of adolescents and young women with suspected endometriosis.

METHODS

A retrospective study of adolescents and young women (12-22 years-old) who were evaluated for suspected endometriosis at the endometriosis clinic in the Shamir medical center between January 2017 and December 2022. All patients were referred by their primary care gynecologists. The evaluation in the endometriosis clinic included targeted history, physical exam and a focused ultrasound survey for endometriosis (performed trans-abdominally in all cases, and trans-vaginally in sexually active women).

RESULTS

Out of 400 women with suspected endometriosis evaluated in our endometriosis clinic during the study period, 68 were adolescents and young women <22 years old. Their mean age at time of evaluation for endometriosis was 18 ± 2.5 years, and the mean time-period from onset of symptoms to the endometriosis evaluation was 4.0 ± 2.9 years. Their most common symptoms were dysmenorrhea (in 61 cases, 89.7 %), followed by gastrointestinal symptoms (in 32 cases, 47.1 %). In 30 (44.1 %) cases, hormonal treatment was prescribed by the primary care gynecologist prior to their appointment in the endometriosis clinic. On comparison of patients with delay of <4 years (N = 31) versus ≥4 years (N = 37) from symptom onset to the endometriosis evaluation, patients with shorter duration of symptoms were more likely to decline any hormonal treatment for endometriosis while patients with longer duration of symptoms were more likely to accept the recommendation for hormonal treatment (16.2 % versus 0 %, p = 0.02, and 83.8 % versus 100 %, p = 0.03, respectively).

CONCLUSION

Adolescents and young women with suspected endometriosis may experience significant delays in diagnosis and medical care, similar to adult patients.

Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms

Background

The #Enzian classification represents a system to describe endometriotic lesions during surgery. Its use is well established in correlating ultrasound and surgical findings.

Objectives

To describe interobserver reproducibility of ultrasound use and symptom correlation with compartments involved using #Enzian classification.

Materials and Methods

Two experienced operators performed transvaginal sonography (TVS) in 52 patients affected by pelvic endometriosis. A rate agreement was determined. A further 200 women with endometriotic TVS signs, with no previous surgery and not taking any hormonal therapy, were staged by one of three different operators according to the #Enzian (compartments A, B, C, O, T, FA, FB, FI, FU, FO). Statistical analysis compared all the compartments, as single or associated, with single or combined symptoms (dysmenorrhea, dyspareunia, heavy menstrual bleeding - HMB, bowel symptoms).

Main outcome measures

Evaluation of the reproducibility of #Enzian classification in assessing pelvic endometriosis among different operators using TVS, and of possible associations between symptoms and specific #Enzian compartments.

Results

Excellent agreement between the two operators in evaluating almost all the compartments (k >0.8) was observed. Dysmenorrhea did not correlate with any specific compartment. We observed a significant association between dyspareunia and B compartment (p=0.02). HMB is associated with FA (p=0.02). Bowel symptoms were associated with B (p=0.02). Combining more symptoms, we observed more significant associations with different compartments.

Conclusions

#ENZIAN classification is reproducible in the evaluation of pelvic endometriosis. Some symptoms are correlated to specific ultrasound signs of the disease.

What is new?

An accurate evaluation of symptoms could guide TVS examination to detect specific endometriotic lesions and establish the best management for the patients.

Correlation between endometriosis and migraine features: Results from a prospective case-control study

BACKGROUND

Endometriosis and migraine frequently coexist, but only a limited number of studies have focused on their mutual association. The aim of our study was to investigate, in untreated women with comorbid endometriosis/adenomyosis and migraine, the correlation between headache features and endometriotic subtypes and their possible relationship with pain severity and disease disability.

METHODS

Fifty women affected by endometriosis/adenomyosis and migraine matched (1:2) with 100 patients with endometriosis alone and 100 patients with only migraine were recruited and underwent pelvic ultrasound imaging and neurological examination.

RESULTS

Severe adenomyosis, posterior and anterior deep infiltrating endometriosis (p = 0.027, p = 0.0031 and p = 0.029, respectively) occurred more frequently in women with migraine. Dysmenorrhea was the most commonly reported symptom in women with endometriosis and migraine and the mean VAS scores of all typical endometriotic symptoms were significantly higher in the presence of comorbidity. Women with both migraine and endometriosis reported significant higher pain intensity (p = 0.004), higher monthly migraine days (p = 0.042) and increased HIT 6-scores (p = 0.01), compared with those without endometriosis.

CONCLUSIONS

Our results demonstrated that the co-occurrence of migraine in untreated women with endometriosis is associated with more severe gynecological infiltrations and correlated with increased pain intensity and disease disability.Trial Registration: Protocol number 119/21.

Reproductive outcome after in vitro fertilization in endometriosis - key factors and implications

Endometriosis is a benign chronic disease with a major impact on a woman's quality of life, mainly due to painful physical symptoms. Endometriosis is also a common cause of infertility caused by low ovarian reserve, distorted pelvic anatomy, and severe local inflammation with a direct negative impact on the quality of oocytes, embryos, and endometrium. We conducted a retrospective study between January 2019 and December 2023, including women with a history of surgery for endometriosis who underwent in vitro fertilization (IVF) to achieve pregnancy. Their reproductive outcome was compared with a group of patients with documented tubal obstruction. The aim of our study was to identify the factors associated with a positive impact on the pregnancy rate, specifically age, anti-Mullerian hormone (AMH), ovarian stimulation protocol, and types of gonadotropins used. We analyzed a group of 175 patients with endometriosis compared with 189 patients with tubal obstruction. The average age was similar between the two groups but with a difference in the average AMH value (1.63 ± 1.09 ng/mL vs. 2.55 ± 1.67 ng/mL). The most utilized ovarian stimulation protocol in both groups was the short gonadotropin-releasing hormone (GnRH) antagonist. The clinical pregnancy rate was 27.2% in the endometriosis group and 54.7% in the tubal obstruction group. Our study revealed that treatment with corifollitropin alfa in the endometriosis group was associated with a higher clinical pregnancy rate. AMH and age proved to be significant independent factors for the reproductive outcome.

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study

OBJECTIVE

The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria.

DESIGN

A diagnostic accuracy study was employed based on a prospective observational design.

PARTICIPANTS

All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered.

SETTING

The study was conducted at endometriosis referral hospitals.

METHODS

We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard.

RESULTS

In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70-96.92%, 95% CI) for the right side and 87.91% (79.40-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90-98.84%, 95% CI) and 96.22% (94.04-97.74%, 95% CI), respectively.

LIMITATIONS

The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives.

CONCLUSIONS

TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Diagnostic accuracy of the IDEA protocol for non invasive diagnosis of rectosigmoid DE - a prospective cohort study

OBJECTIVES

 To test the accuracy of TVS applying the IDEA approach for suspected rectosigmoid DE and to determine the frequency of other pelvic diseases mimicking DE in patients undergoing surgery.

MATERIALS UND METHODS

 Prospective single center observational study including consecutive women undergoing TVS for clinically suspected rectosigmoid DE followed by conservative or surgical therapy. TVS findings were compared with those obtained by laparoscopy and confirmed histologically.

RESULTS

 Of the 671 included patients, 128 women opted for medical therapy, and 6 patients decided for surgery but did not give consent to participate in the study. 537 women were enrolled in the final analysis. 279 (52 %) exhibited surgically confirmed rectosigmoid DE. The sensitivity and specificity, positive and negative predictive value (PPV, NPV), positive and negative likelihood ratio (LR+/-) and accuracy of TVS for diagnosing DE in the rectosigmoid were 93.5 %, 94.6 %, 94.9 %, 93.1 %, 17.24, 0.07, 94.04 %. 12 women who were clinically suspected for DE and mimicked sonographic signs fulfilling the IDEA criteria did exhibit other pathologies. Diagnoses were as follows: vaginal Gartner duct cyst (3/291;1.0 %), anorectal abscess (3/291; 1.0 %), rectal cancer (2/291;0.7 %), hydrosalpinx (2/291;0.7 %), metastatic endometrial cancer (1/291;0.35 %) and Crohn's disease (1/291;0.35 %).

CONCLUSION

 TVS for diagnosing colorectal DE applying the IDEA criteria is highly accurate for presurgical diagnosis. However, additional pelvic pathologies are encountered in 4-5 % of women attending for suspected rectosigmoid DE. These need to be taken into account when investigating patients for suspected DE.

Noninvasive diagnostic imaging for endometriosis part 1: a systematic review of recent developments in ultrasound, combination imaging, and artificial intelligence

Endometriosis affects 1 in 9 women and those assigned female at birth. However, it takes 6.4 years to diagnose using the conventional standard of laparoscopy. Noninvasive imaging enables a timelier diagnosis, reducing diagnostic delay as well as the risk and expense of surgery. This review updates the exponentially increasing literature exploring the diagnostic value of endometriosis specialist transvaginal ultrasound (eTVUS), combinations of eTVUS and specialist magnetic resonance imaging, and artificial intelligence. Concentrating on literature that emerged after the publication of the IDEA consensus in 2016, we identified 6192 publications and reviewed 49 studies focused on diagnosing endometriosis using emerging imaging techniques. The diagnostic performance of eTVUS continues to improve but there are still limitations. eTVUS reliably detects ovarian endometriomas, shows high specificity for deep endometriosis and should be considered diagnostic. However, a negative scan cannot preclude endometriosis as eTVUS shows moderate sensitivity scores for deep endometriosis, with the sonographic evaluation of superficial endometriosis still in its infancy. The fast-growing area of artificial intelligence in endometriosis detection is still evolving, but shows great promise, particularly in the area of combined multimodal techniques. We finalize our commentary by exploring the implications of practice change for surgeons, sonographers, radiologists, and fertility specialists. Direct benefits for endometriosis patients include reduced diagnostic delay, better access to targeted therapeutics, higher quality operative procedures, and improved fertility treatment plans.

Noninvasive diagnostic imaging for endometriosis part 2: a systematic review of recent developments in magnetic resonance imaging, nuclear medicine and computed tomography

Endometriosis affects 1 in 9 women, taking 6.4 years to diagnose using conventional laparoscopy. Non-invasive imaging enables timelier diagnosis, reducing diagnostic delay, risk and expense of surgery. This review updates literature exploring the diagnostic value of specialist endometriosis magnetic resonance imaging (eMRI), nuclear medicine (NM) and computed tomography (CT). Searching after the 2016 IDEA consensus, 6192 publications were identified, with 27 studies focused on imaging for endometriosis. eMRI was the subject of 14 papers, NM and CT, 11, and artificial intelligence (AI) utilizing eMRI, 2. eMRI papers describe diagnostic accuracy for endometriosis, methodologies, and innovations. Advantages of eMRI include its: ability to diagnose endometriosis in those unable to tolerate transvaginal endometriosis ultrasound (eTVUS); a panoramic pelvic view, easy translation to surgical fields; identification of hyperintense iron in endometriotic lesions; and ability to identify super-pelvic lesions. Sequence standardization means eMRI is less operator-dependent than eTVUS, but higher costs limit its role to a secondary diagnostic modality. eMRI for deep and ovarian endometriosis has sensitivities of 91-93.5% and specificities of 86-87.5% making it reliable for surgical mapping and diagnosis. Superficial lesions too small for detection in larger capture sequences, means a negative eMRI doesn't exclude endometriosis. Combined with thin sequence capture and improved reader expertise, eMRI is poised for rapid adoption into clinical practice. NM labeling is diagnostically limited in absence of suitable unique marker for endometrial-like tissue. CT studies expose the reproductively aged to radiation. AI diagnostic tools, combining independent eMRI and eTVUS endometriosis markers, may result in powerful capability. Broader eMRI use, will optimize standards and protocols. Reporting systems correlating to surgical anatomy will facilitate interdisciplinary preoperative dialogues. eMRI endometriosis diagnosis should reduce repeat surgeries with mental and physical health benefits for patients. There is potential for early eMRI diagnoses to prevent chronic pain syndromes and protect fertility outcomes.

Adenomyosis and endometriosis in adolescents and young women with pelvic pain: prevalence and risk factors

BACKGROUND

The aim of this study was to evaluate the prevalence of ultrasound diagnosis of adenomyosis and endometriosis in young women complaining of pelvic pain and to find the symptoms and clinical characteristics associated with these diseases in young women.

METHODS

Cross-sectional study, including 100 young women (14-24 years) with a history of chronic pelvic pain. Women were asked detailed medical hystory and pain symptoms scores (Visual Analogue Scale) and underwent gynecological examination and ultrasound evaluation.

RESULTS

The prevalence of endometriosis and adenomyosis in young women amounted to 25.0% and 46.0%, respectively. A significant correlation was found between ovarian endometriosis and adenomyosis. Dysmenorrhea and dyspareunia were risk factors for adenomyosis. Dyschezia, dyspareunia, chronic pelvic pain, presence of sonographic soft markers suggestive of pelvic adhesions, being a worker and having a previous surgery were risk factors for endometriosis. Young women (20-24 years) had a higher incidence of both adenomyosis and endometriosis than adolescents (14-19 years).

CONCLUSIONS

Our outcomes strengthen the hypothesis of a progressive and common course of the natural history of endometriosis, which initially may manifest with symptoms, then with signs of pelvic adhesions and finally as adenomyosis, ovarian endometriomas or deep infiltrating endometriosis.

Prospective diagnostic test accuracy of transvaginal ultrasound posterior approach for uterosacral ligament and torus uterinus deep endometriosis

OBJECTIVE

To determine the diagnostic test accuracy of transvaginal ultrasound (TVS) using a standardized technique for the diagnosis of deep endometriosis (DE) of the uterosacral ligaments (USLs) and adjacent torus uterinus (TU).

METHODS

This was a prospective diagnostic test accuracy study conducted at the McMaster University Medical Center Tertiary Endometriosis Clinic, Hamilton, ON, Canada. Consecutive participants were enrolled if they successfully underwent TVS and surgery by our team from 10 August 2020 to 31 October 2021. The index test was TVS using a standardized posterior approach performed and interpreted by an expert sonologist. The reference standard included direct surgical visualization on laparoscopy by the same person who performed and interpreted the ultrasound scans. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios were calculated for the TVS posterior approach for each location using the reference standard.

RESULTS

There were 54 consecutive participants included upon completion of laparoscopy and histological assessment. The prevalence of DE for the left USL, right USL and TU was 42.6%, 22.2% and 14.8%, respectively. Based on surgical visualization as the reference standard, TVS demonstrated an accuracy of 92.6% (95% CI, 82.1-97.9%), sensitivity of 82.6% (95% CI, 61.2-95.1%), specificity of 100% (95% CI, 88.8-100%), PPV of 100% and NPV of 88.6% (95% CI, 76.1-95.0%) for diagnosing DE in the left USL. For DE of the right USL, TVS demonstrated an accuracy of 94.4% (95% CI, 84.6-98.8%), sensitivity of 75.0% (95% CI, 42.8-94.5%), specificity of 100% (95% CI, 91.6-100%), PPV of 100% and NPV of 93.3% (95% CI, 84.0-97.4%). For DE of the TU, TVS demonstrated an accuracy of 100% (95% CI, 93.4-100%), sensitivity of 100% (95% CI, 63.1-100%), specificity of 100% (95% CI, 92.3-100%), PPV of 100% and NPV of 100%.

CONCLUSIONS

We observed high diagnostic test accuracy of the evaluated standardized TVS technique for assessing DE of the USLs and TU. Further studies evaluating this technique should be performed, particularly with less experienced observers, before considering this technique as the standard approach. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound appearance of decidualized non-ovarian endometriotic lesions during pregnancy and after delivery

OBJECTIVE

To evaluate the changes in the ultrasound characteristics of decidualized non-ovarian endometriotic lesions that occur during pregnancy and after delivery.

METHODS

This was a prospective observational cohort study carried out at a single tertiary center between December 2018 and October 2021. Pregnant women with endometriosis underwent a standardized transvaginal ultrasound examination with color Doppler imaging once in every trimester and after delivery. Non-ovarian endometriotic lesions were measured and evaluated by subjective semiquantitative assessment of blood flow. Lesions with moderate-to-marked blood flow were considered decidualized. The size and vascularization of decidualized and non-decidualized lesions were compared between the gravid state and after delivery. Only patients with non-ovarian endometriotic lesion(s) who underwent postpartum examination were included in the final analysis.

RESULTS

Overall, 26 pregnant women with a surgical or sonographic diagnosis of endometriosis made prior to conception were invited to participate in the study, of whom 24 were recruited. Of those, 13 women with non-ovarian endometriosis who attended the postpartum examination were included. In 7/13 (54%) cases, the lesion(s) were decidualized. In 4/7 (57%) women with decidualized lesion(s), the size of the largest lesion increased during pregnancy, while in 3/7 (43%), the size was unchanged. The size of non-decidualized lesions did not change during pregnancy. On postpartum examination, only seven lesions were observed, of which three were formerly decidualized and four were formerly non-decidualized. Lesions that were detected after delivery appeared as typical endometriotic nodules and were smaller compared with during pregnancy. The difference in maximum diameter between the gravid and postpartum states was statistically significant in decidualized lesions (P < 0.01), but not in non-decidualized lesions (P = 0.09). The reduction in mean diameter was greater in decidualized compared with non-decidualized lesions (P = 0.03).

CONCLUSIONS

Decidualization was observed in 54% of women with non-ovarian endometriotic lesion(s) and resolved after delivery. Our findings suggest that the sonographic features of decidualization, which might mimic malignancy, are pregnancy-related and that expectant management and careful monitoring should be applied in these cases. Clinicians should be aware of the changes observed during pregnancy to avoid misdiagnosing decidualized lesions as malignancy and performing unnecessary surgery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Role of ultrasonography in the diagnosis of endometriosis in infertile women: Ovarian endometrioma, deep endometriosis, and superficial endometriosis

Endometriosis is a complex chronic inflammatory process characterised by the presence of endometrial-like glandular tissue outside the uterine cavity, typically within the pelvic structures. This condition affects up to 10-15 % of women and those assigned female at birth, and can result in chronic pelvic pain and in/subfertility. Treatment goals include medical, surgical options and alternative therapies. Transvaginal ultrasound (TVUS) is the currently recommended first line investigation for endometriosis with magnetic resonance imaging (MRI) reserved for those with equivocal ultrasound findings. In this paper, we aim to outline the commonly seen sonographic appearances of endometriosis divided into anterior, middle and posterior pelvic compartments. Limitations to ultrasound imaging include high operator dependence and patient factors. New imaging techniques and research into the utility of artificial intelligence (AI) into the detection of endometriosis is currently underway, with possibility of reduced diagnostic delay and better patient outcomes.

The Benefit of Transvaginal Elastography in Detecting Deep Endometriosis: A Feasibility Study

OBJECTIVES

This study aimed to evaluate elastography features of deep infiltrating endometriosis (DIE), and to define whether this technique may discriminate lesions from surrounding non-endometriotic tissue.

METHODS

This was an exploratory observational study on women affected by DIE treated in a third-level academic hospital gynaecology outpatient facility between 2020 and 2021. Strain elastography (SE) was conducted via transvaginal probe. Tissue deformation of DIE and surrounding tissue was expressed as percentage tissue deformation or as subjective colour score (CS; from blue=stiff to red=soft, assigned numerical values from 0 to 3). Ratios of normal tissue/DIE were compared to ratio of normal tissue/stiffer normal tissue area.

RESULTS

Evaluations were performed on 46 DIE nodules and surrounding tissue of the uterosacral ligaments (n=21), parametrium (n=7), rectum (n=14), and recto-vaginal septum (n =4). Irrespective of location, DIE strain ratio (3.09, IQR 2.38-4.14 vs. 1.25, IQR 1.11-1.48; p<0.001) and CS ratio (4.62, IQR 3.83-6.94 vs. 1.13, IQR 1.06-1.29; p<0.001) was significantly higher than that of normal tissue. ROC AUC of CS ratio was higher than ROC AUC of strain ratio (99.76%, CI.95 99.26-100% vs. 91.35%, CI.95 85.23-97.47%; p=0.007), and best ROC threshold for CS ratio was 1.82, with a sensitivity of 97.83% (CI.95 93.48-100%) and a specificity of 100% (CI.95 100-100%).

CONCLUSIONS

Both strain and CS ratios accurately distinguish DIE nodules at various locations. Applications of elastography in improving the diagnosis DIE, in distinguishing different DIE lesions and in monitoring DIE evolution can be envisioned and are worthy of further evaluation.

Endometriosis MR mimickers: T2-hypointense lesions

Endometriosis is a common crippling disease in women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While its sensitivity, especially in deep infiltrating endometriosis, is superior to that of ultrasonography, many sources of false-positive results exist, leading to a lack of specificity. Hypointense lesions or pseudo-lesions on T2-weighted images include anatomical variants, fibrous connective tissues, benign and malignant tumors, feces, surgical materials, and post treatment scars which may mimic deep pelvic infiltrating endometriosis. False positives can have a major impact on patient management, from diagnosis to medical or surgical treatment. This educational review aims to help the radiologist acknowledge MRI criteria, pitfalls, and the differential diagnosis of deep pelvic infiltrating endometriosis to reduce false-positive results. Critical relevance statement MRI in deep infiltrating endometriosis has a 23% false-positive rate, leading to misdiagnosis. T2-hypointense lesions primarily result from anatomical variations, fibrous connective tissue, benign and malignant tumors, feces, surgical material, and post-treatment scars. Key points • MRI in DIE has a 23% false-positive rate, leading to potential misdiagnosis.• Anatomical variations, fibrous connective tissues, neoplasms, and surgical alterations are the main sources of T2-hypointense mimickers.• Multisequence interpretation, morphologic assessment, and precise anatomic localization are crucial to prevent overdiagnosis.• Gadolinium injection is beneficial for assessing endometriosis differential diagnosis only in specific conditions.

Not All Bad Comes to Harm: Enhanced Recovery After Surgery for Rectosigmoid Endometriosis

STUDY OBJECTIVE

To assess the impact of implementing an enhanced recovery after surgery (ERAS) protocol on the length of hospitalization in women undergoing laparoscopy for rectosigmoid deep infiltrating endometriosis (DIE).

DESIGN

A retrospective cohort study.

SETTING

An academic referral center for endometriosis and minimally invasive gynecologic surgery.

PATIENTS

Women aged between 18 and 50 years scheduled for laparoscopic excision (shaving, full-thickness anterior wall resection, segmental resection) of rectosigmoid endometriosis between February 2017 and February 2023.

INTERVENTIONS

We divided patients into 2 groups (non-ERAS and ERAS) based on the timing of surgery (before or after March 5, 2020). Starting from this day, restrictions were issued to limit the spread of the coronavirus disease 2019 pandemic, inducing our group to implement an ERAS protocol for patients hospitalized after surgery for posterior DIE.

MEASUREMENTS AND MAIN RESULTS

We included 579 patients in the analysis, 316 (54.6%) in the non-ERAS group and 263 (45.4%) in the ERAS group. In the ERAS group, we observed a shorter length of hospital stay (5.8 ± 3.1 days vs 4.8 ± 2.9 days; p <.001) and lower complications rates (33, 12.5% vs 60, 19.0%; p = .04), despite a decreased frequency of conservative surgical approaches (shaving procedures 121 vs 196; p <.001). Repeated surgery or hospital readmissions owing to postdischarge complications were infrequent, with no significant differences between the 2 groups. The multiple linear regression analysis strengthened our results given the higher prevalence of bowel resection surgeries (both full-thickness anterior wall or segmental), showing that patients managed with a multimodal protocol had an overall reduction of hospital stay by 1.5 days.

CONCLUSION

The implementation of an ERAS program in patients undergoing laparoscopic surgery for DIE is associated with a significant reduction in hospital stay, without an increase in perioperative or postoperative complication rates.

Diagnosis of superficial endometriosis on transvaginal ultrasound by visualization of peritoneum of pouch of Douglas

OBJECTIVE

Around 80% of women with endometriosis have superficial endometriosis (SE) rather than ovarian or deep endometriosis (DE). However, to date, advances in non-invasive, imaging-based diagnosis have been limited to DE or ovarian disease. The objective of this study was to determine whether we can detect SE on transvaginal ultrasound scan (TVS) by assessing the peritoneum of the pouch of Douglas (POD).

METHODS

This was a retrospective diagnostic test study following a change in practice to include POD peritoneum assessment for SE during TVS at a tertiary London hospital. Eligible patients underwent TVS by a single clinician trained in endometriosis scanning and a subsequent surgical procedure (laparoscopy) between April 2018 and September 2021. Participants formed a consecutive series. The TVS findings were compared with those of laparoscopy as the gold standard. Comparison of TVS findings with intraoperative findings was performed by calculating the diagnostic test performance measures (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive and negative likelihood ratios).

RESULTS

The study included a total of 100 patients. We found that 43/100 (43.0%) patients had no endometriosis, 33/100 (33.0%) had SE and 24/100 (24.0%) had DE on laparoscopy. SE was correctly detected on TVS in 17/33 patients, with a sensitivity of 51.5% (95% CI, 33.5-69.2%), specificity of 94.0% (95% CI, 85.4-98.4%), PPV of 81.0% (95% CI, 60.8-92.1%) and NPV of 79.7% (95% CI, 73.4-84.9%). DE was correctly diagnosed in 20/24 cases, including all ovarian cases, with a sensitivity of 83.3% (95% CI, 62.3-95.3%), specificity of 97.4% (95% CI, 90.8-99.7%), PPV of 90.9% (95% CI, 71.6-97.5%) and NPV of 94.9% (95% CI, 88.3-97.8%). The detection of SE on TVS was most accurate in the POD (sensitivity, 50.0%; specificity, 96.4%; PPV, 76.9%; NPV, 88.9%).

CONCLUSIONS

This study shows that the detection of SE in the POD is possible using routine TVS. While negative TVS does not reliably confirm the absence of disease or replace diagnostic laparoscopy, positive TVS facilitates non-invasive diagnosis for a much larger group of women than was previously possible. This should help to reduce the time from the onset of symptoms to diagnosis and enable initiation of medical treatment without the risk, cost and delay associated with a surgical diagnosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Developing a set of patient-centered outcomes for routine use in endometriosis: An international Delphi study

INTRODUCTION

There is large variation in individual patient care for endometriosis. A uniform approach to measure outcomes could be incorporated into routine clinical practice to personalize and monitor treatments and potentially improve the quality of care. The aim of this study is to identify a group of patient-centered outcomes for use in routine endometriosis care which are relevant to all patient profiles.

MATERIAL AND METHODS

By means of a modified two-round Delphi study with international representation including healthcare professionals, researchers and patient representatives (51 participants, 16 countries) we developed a set of patient-centered measurements. The participants evaluated 47 Patient Reported Outcome Measures (PROMs) and 30 Clinician Reported Outcome Measures (CROMs) regarding their feasibility and relevance for their use in routine endometriosis care. After the two rounds of quotation, meetings of the experts were convened to participate in a final discussion to finalize the consensus of the final set of included measures.

RESULTS

The final set of patient-centered outcomes includes six PROMs (measuring symptomatic impact, pain, work productivity and quality of life) and 10 CROMs (measuring clinical, imaging and surgical indicators). A supplementary list of outcomes was added to include important dimensions that were considered essential by the expert panel but are not relevant to all patients. In addition the need for development of specific tools (PROMs) measuring the psychological impact and the impact in sexual activity of endometriosis was highlighted.

CONCLUSIONS

We have developed a set of patient-centered outcomes measures in endometriosis care. The selected outcomes comprise the common features for all patients suffering from endometriosis. adapted for use in routine practice. The list of outcomes has been adapted for use in routine practice from which clinicians can chose, depending on their needs.

Comprehensive endometriosis care: a modern multimodal approach for the treatment of pelvic pain and endometriosis

Endometriosis is a prevalent gynecological disease, leading to chronic pain and inflammation, affecting 1 in 10 individuals presumed female at birth. The diagnostic journey is often arduous, marked by neglect of the right diagnosis and prolonged wait times, significantly compromising the quality of life among those affected. This review provides a nuanced exploration of endometriosis-associated pain management, encompassing medical, surgical, and holistic approaches, all guided by accurate and refined diagnostics. Our paramount goal is to empower physicians as key figures in confronting this intricate challenge with a patient-centric approach, ultimately aiming to improve treatment and quality of life. Acknowledging each patient's unique needs, we emphasize the importance of tailoring a spectrum of options informed by current literature and insights gleaned from our experience in a high-volume tertiary endometriosis center. It is imperative to recognize endometriosis as a complex and chronic disease, often occurring with co-morbid conditions and nuanced complexities, necessitating a long-term personalized multimodal approach for each case. In addition, incorporating principles such as patient autonomy, profound respect for diverse experiences, and practical education on treatment choices is pivotal in enhancing treatment outcomes and overall patient satisfaction.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial

BACKGROUND

The conventional laparoscopic approach for the surgical management of deep endometriosis (DE) infiltrating the rectum appears to ensure improved digestive functional outcomes. The natural orifice specimen extraction (NOSE) technique for the treatment of colorectal DE can significantly accelerate postoperative recovery; however, data on gastrointestinal function following conventional laparoscopic segmental bowel resection (CLR) compared with NOSE colectomy (NC) for DE are sparse.

MATERIALS AND METHODS

Between 30 September 2019 and 31 December 2020, a randomized, open-label, two-arm, parallel-group controlled trial with women aged 18-45 years was conducted at University Hospital.Ninety-nine patients were randomized to CLR or NC, with DE infiltrating at least the muscular layer, at least 50% of the circumference of the bowel, up to 15 cm from the anal verge, exhibiting pain and bowel symptoms and/or infertility. The primary endpoint was bowel function, represented by low anterior resection syndrome (LARS). Secondary parameters included the Endometriosis Health Profile 30 (EHP30), Gastrointestinal Quality of Life Index (GIQLI), Visual Analog Scale (VAS) scores preoperatively and at set times (1 and 6 months, 1 year) following surgery.

RESULTS

No significant differences were observed in the postoperative LARS scores, VAS, EHP30, and GIQLI between the NC and CLR groups. LARS scores did not reveal significant differences 12 months postoperatively compared to the preoperative values in both groups (CLR group P =0.93 versus NC group, P =0.87). GIQLI scores were significantly improved 12 months after the operation compared with baseline values in the CLR group ( P =0.002) and NC group ( P =0.001). Pain symptoms and quality of life scores significantly improved 12 months postoperatively in both groups.

CONCLUSIONS

NC is a feasible surgical approach for treating patients with rectal DE. Our study did not show a statistically significant difference between CLR and NC techniques in mid-term digestive and pain outcomes.

Is endometrial receptivity affected in women with endometriosis? Results from a matched pair case-control study of assisted reproductive technology treatments

RESEARCH QUESTION

Is endometriosis detrimental to embryo implantation?

DESIGN

A retrospective matched case-control study of women with a surgical or ultrasound diagnosis of endometriosis at Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico di Milano between 2015 and 2021. Women with endometriosis who underwent a 'freeze-all' cycle during an IVF treatment were eligible to be included. They were matched to patients without the disease, who also underwent cryopreserved blastocyst transfer cycles, in a 1:1 ratio by age (±1 year), and number (=) and quality (±1 top versus low) of cryopreserved blastocysts. All women underwent single frozen embryo transfer, and assisted reproductive technology outcomes suggested by the Core Outcome Measure for Infertility Trials initiative were evaluated. The main outcome was the cumulative live birth rate per cycle.

RESULTS

One hundred and one women with endometriosis and 101 matched unaffected women were included. Cumulative live birth rate per cycle did not vary between women with and without endometriosis (50% versus 58%, respectively; P = 0.32). On the basis of the Kaplan-Meier analysis, the predicted success rates over four embryos transferred were also similar (74% versus 82%, respectively; P = 0.67).

CONCLUSION

In women with moderate or severe endometriosis, these retrospective results seem to indicate no or a limited effect of the disease on endometrial receptivity.

Does Sexual Function and Quality of Life Improve after Medical Therapy in Women with Endometriosis? A Single-Institution Retrospective Analysis

BACKGROUND

Endometriosis is a gynecological condition affecting up to 10% of women of reproductive age and characterized by chronic pain. Pain is the major cause of the impairment of quality of life in all aspects of these patients. Previous studies have shown that endometriosis treatment, hormonal or surgical, has proven effective not only in controlling the disease but also in improving symptoms, and we can assume also effective in improving quality of life.

METHODS

This study evaluates quality of life and sexual function in patients with endometriosis at the time of diagnosis and after 6 months of medical therapy, to assess the impact of treatment on these aspects. We evaluated retrospectively patients with a diagnosis of endometriosis between 2018 and 2020. All patients underwent gynecological examination and transvaginal ultrasound and filled in three questionnaires. The same evaluation was provided after taking medical hormonal therapy.

RESULTS

The improvement of dysmenorrhea, chronic pelvic pain, and dyspareunia after medical treatment were statistically significant. Instead, items concerning arousal, lubrication, and sexual satisfaction showed a statistically significant worsening after therapy.

CONCLUSIONS

We can state that hormone therapy alone is not sufficient to achieve an improvement in the patient's quality of life and sexual function. Emerging evidence suggests that most of these patients showed a central sensibilization phenomenon characterized by an amplification of the response to a peripheral and/or neuropathic nociceptive trigger, which is expressed by hyperalgesia and allodynia. For this reason, in these patients, it is better to adopt a multimodal and multidisciplinary approach, including other professional figures, that acts on pain and also intervenes in all those conditions that contribute to worsening quality of life.

CAR Practice Statement on Advanced Pelvic Ultrasound for Endometriosis

The Canadian Association of Radiologists (CAR) Endometriosis Working Group was tasked with providing guidance and benchmarks to ensure the quality of technique and interpretation for advanced imaging modalities associated with diagnosing endometriosis. This practice statement provides an overview of the state of the art of advanced pelvic ultrasound in the diagnosis and mapping of pelvic endometriosis. While acknowledging that advanced pelvic ultrasound in some practices falls within the scope of clinical colleagues rather than imaging departments, the statement seeks to guide radiologists interested in implementing these techniques into their practice for patients referred for evaluation and diagnosis of endometriosis. The statement covers indications, some components of the ultrasound assessment and technique, reporting, and recommendations for starting an ultrasound endometriosis evaluation program.

Homozygous C677T Methylenetetrahydrofolate Reductase (MTHFR) Polymorphism as a Risk Factor for Endometriosis: A Retrospective Case-Control Study

This study was conducted to evaluate the role of methylenetetrahydrofolate reductase (MTHFR) C677T homozygous polymorphism as a risk factor for endometriosis. A retrospective case-control study was conducted from January 2020 to December 2022 on all patients attending the gynecological outpatient clinic of our institution who had performed an MTHFR polymorphisms test. Patients with endometriosis were considered cases, while those without endometriosis were considered controls. The presence of an MTHFR C677T homozygous polymorphism was defined as exposure. Risk factors for endometriosis were considered confounders in a binomial logistic regression, with endometriosis diagnosis as the dependent variable. Among the 409 included patients, 106 (25.9%) cases and 303 (74.1%) controls were identified. A higher rate of MTHFR C677T homozygous polymorphism was found in patients with endometriosis (24.5% vs. 15.8%, p = 0.0453), with an adOR of 1.889 (95% CI 1.076-3.318, p = 0.0269) at the binomial logistic regression. A history of no previous pregnancy was associated with an endometriosis diagnosis (adOR 2.191, 95% CI 1.295-3.708, p = 0.0035). An MTHFR C677T homozygous polymorphism could be considered a risk factor for endometriosis. Epigenetic modifications may be the most important mechanism explaining the observed association through the processes of altered DNA methylation and reduced activity of antioxidant systems.

Dienogest alone or dienogest combined with estrogens in the treatment of ovarian endometriomas, that is the question. A retrospective cohort study

PURPOSE

to compare the effects of Dienogest 2 mg (D) alone or combined with estrogens (D + ethinylestradiol 0.03 mg, D + EE; D + estradiol valerate 1-3 mg, D + EV) in terms of symptoms and endometriotic lesions variations.

METHODS

This retrospective study included symptomatic patients in reproductive age with ultrasound diagnosis of ovarian endometriomas. Medical therapy for at least 12 months with D, D + EE or D + EV was required. Women were evaluated at baseline visit (V1) and after 6 (V2) and 12 months (V3) of therapy.

RESULTS

297 patients were enrolled (156 in the D group, 58 in the D + EE group, 83 in the D + EV group). Medical treatment leaded to a significant reduction in size of endometriomas after 12 months, with no differences between the three groups. When comparing D and D + EE/D + EV groups, a significant decrease of dysmenorrhea was detected in the D group than in D + EE/D + EV group. Conversely, the reduction of dysuria was more significative in the D + EE/D + EV groups rather than in the D group. Regarding tolerability, treatment associated side effects were reported by 16.2% patients. The most frequent one was uterine bleeding/spotting, significantly higher in the D + EV group.

CONCLUSION

Dienogest alone or associated with estrogens (EE/EV) seems to be equally effective in reducing endometriotic lesions mean diameter. The reduction of dysmenorrhea was more significative when D was administered alone, while dysuria seems to improve more when D is associated with estrogens.

Intra- and interobserver reproducibility of transvaginal ultrasound for the detection and measurement of endometriotic lesions of the bowel

INTRODUCTION

The number and invasion depth of endometriotic bowel lesions, total length of bowel affected by endometriosis, lesion-to-anal verge distance, and extent of pouch of Douglas obliteration are important factors in preoperatively determining risk and complexity of endometriosis surgery. The intra- and interobserver reproducibility of transvaginal ultrasound in the evaluation of many of these parameters has not yet been investigated. Our study aimed to assess the intra- and interobserver reproducibility of transvaginal ultrasound between an experienced and less experienced examiner for all of these parameters.

MATERIAL AND METHODS

This prospective observational cross-sectional study was conducted between July 2019 and November 2020. Fifty consecutive premenopausal women who underwent transvaginal ultrasound examination in our clinic for the first time, were examined by the same two operators during the same attendance. Outcomes of interest were the inter-rater reproducibility of transvaginal ultrasound for detecting the presence, number, depth and size of bowel endometriotic nodules, lesion-to-anal-verge distance, total length of bowel affected, and pouch of Douglas obliteration. The intraobserver reproducibility was assessed for the continuous parameters. Cohen's kappa (κ) statistic, Cohen's weighted kappa (κ), proportions of agreement, intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement were used to assess the reproducibility of the parameters.

RESULTS

The inter-rater agreement and reliability were very good for identifying bowel endometriosis, the number and invasion depth of bowel nodules, determining whether the maximum nodule length was <3 cm, and lesion-to-anal-verge distance <8 cm (proportion of agreement 0.92, 0.94, 0.97, 0.94, 0.96; κ 0.92, 0.91, 0.92, 0.82, 0.89). The inter-rater agreement and reliability were good for assessing pouch of Douglas obliteration (proportion of agreement 0.86, κ 0.80). The intra-rater reliability for the mean nodule diameter (ICC 0.93 and 0.97) and total length of bowel affected (ICC 0.94 and 0.91) were excellent for operators A and B, respectively. The inter-rater reliability for the mean nodule diameter was good (ICC 0.80), and moderate for the total length of bowel affected (ICC 0.70). The Bland-Altman limits of agreement demonstrated clinically acceptable ranges for these two parameters.

CONCLUSIONS

This study demonstrated a high intra- and inter-rater reproducibility of transvaginal ultrasound in the diagnosis of bowel endometriosis and measurement of its various components.

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

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.

Fluorescence guidance during robotic resection of bladder wall endometriosis: case report and technique

The application of indocyanine green (ICG) has recently been reported to aid in the resection of endometriosis in the bladder wall and/or involving the ureters. A symptomatic 41-year-old patient with dysmenorrhea and pollakisuria was referred to our tertiary center. Imaging revealed a 1.5-2 cm intramural endometriotic nodule in the posterior bladder wall. She was planned for robotic resection of the endometriotic nodule, under ICG guidance, together with a hysterectomy. After placement of double-J ureteral stents and clamping the bladder, perforation of the bladder mucosa could be avoided whilst performing a circumferential resection of the nodule. By clamping the bladder catheter after instillation of ICG, both the bladder wall thickness and ureters could be visualized with near-infrared imaging during robotic resection of the endometriotic nodule and hysterectomy. With the surgical approach described here, endometriotic nodules/tissue can be removed precisely with enlarged vision at the robot console, safely, and completely without damaging adjacent tissues.

Transvaginal Ultrasound vs. Magnetic Resonance Imaging: What Is the Optimal Imaging Modality for the Diagnosis of Endometriosis?

Endometriosis, an intriguing gynecological illness, poses a substantial health concern for women of reproductive age, despite its widespread occurrence and limited comprehension. The objective of this study is to assess the diagnostic precision of transvaginal sonography (TVS) and pelvic magnetic resonance imaging (MRI) for the identification of deep infiltrated endometriosis (DIE). This study encompassed a cohort of 256 patients exhibiting signs and symptoms of endometriosis, with the aim of assessing the diagnostic accuracy over a span of four years. Both TVS and pelvic MRI were employed in the same centers to analyze each subject. The histopathologic analysis and laparoscopy were the most reliable and widely accepted methods for evaluation. TVS is a reliable diagnostic tool for ovarian endometriomas, obviating the necessity for MRI confirmation. The specificity of TVS in diagnosing ovarian endometriomas is 57.14%, while its sensitivity is 93.78%, resulting in an overall accuracy of 84.47%. In relation to parametrial lesions, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: TVS: 9%, 97%, 32%, MRI: 27.14%, 89.19%, and 40.11%. Concerning the uterosacral lesions, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: TVS:14.63%, 94.74%, and 55%, while MRI: 65.88%, 66.30%, and 66.1%. Regarding rectal endometriosis, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: 69.72%, 76.87%, and 73.82% for TVS, and 66.28%, 94.51%, and 80.79% for MRI. The results of the present study indicate that whereas MRI generally exhibits superior capability in assessing the severity of endometriosis, TVS demonstrates sufficient diagnostic accuracy in DIE comparable to MRI.

Endometriosis and dyspareunia: Solving the enigma

Introduction

Endometriosis is a chronic oestrogen-dependent disease that affects 1 in 10 women of childbearing age. Half of these women have deep dyspareunia. The presence of this symptom has been shown to negatively affect your quality of life. There are few studies in the literature that address this issue and its pathophysiology remains poorly understood.

Materials and methods

A case-control study has been carried out in order to assess the multi-causality of dyspareunia in patients with endometriosis. All the patients were assessed in a unit specialising in endometriosis and pelvic pain and their disease was staged using high-resolution ultrasound following the criteria of the IDEA group. The patients were divided into two groups, patients with dyspareunia n = 45 (cases) and those without it n = 55 (controls).

Results

The only element that was statistically significant in explaining the dyspareunia was the presence of nodules in the retrocervical region with p = 0.000. The odds ratio of dyspareunia in the cases group was 5.3 (95 % CI 2.2-12.5).

Conclusions

Dyspareunia in patients with endometriosis is strongly dependent on the presence of nodules in the retrocervical region, although there are other factors involved that remain unknown, so more studies are still needed to understand and optimally address this symptom.

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.