IDEAL study: magnetic resonance imaging for suspected deep endometriosis assessment prior to laparoscopy is as reliable as radiological imaging as a complement to transvaginal ultrasonography

Non-Invasive Imaging Techniques for Diagnosis of Pelvic Deep Endometriosis and Endometriosis Classification Systems: An International Consensus Statement

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), the European Society of Human Reproduction and Embryology (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, counseling and planning of surgical treatment strategies.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement

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), the European Society of Human Reproduction and Embryology (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, counseling and planning of surgical treatment strategies. © 2024 The Authors. Published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology, by Universa Press, by The International Society for Gynecologic Endoscopy, by Oxford University Press on behalf of European Society of Human Reproduction and Embryology, by Elsevier Inc. on behalf of American Association of Gynecologic Laparoscopists and by Elsevier B.V.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement†,‡

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), the European Society of Human Reproduction and Embryology (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 a 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.

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.

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.

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.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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

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

Gastrointestinal symptoms as a predictor of deep endometriosis of the pelvic posterior compartment on magnetic resonance imaging

Objective:

To determine if gastrointestinal (GI) symptoms can predict deep endometriosis (DE) of the posterior pelvic compartment on magnetic resonance imaging (MRI).

Methods:

Patients with suspected endometriosis undergoing endometriosis protocol MRI at an academic center between 9/1/2015 and 7/31/2018 were identified. Presenting GI symptoms were collected via a standardized survey instrument prospectively at initial presentation. MRI and interdisciplinary conference notes were reviewed to identify posterior compartment DE (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DE were evaluated.

Results:

A total of 104 patients met inclusion criteria, and 89 (85.6%) presented with at least one GI symptom. Posterior compartment DE was identified on MRI in 47 patients (45.2%). The GI symptom that most strongly predicted DE was a bowel movement resulting in pain relief (OR 3.36, 95% CI 1.31–8.61, p = 0.012), with sensitivity, specificity, positive and negative predictive values 0.42, 0.82, 0.67, and 0.63, respectively. Other GI symptoms such as nausea, vomiting, rectal bleeding, change in frequency of bowel movements, and pain exacerbation by bowel movements did not significantly correlate to having DE. Of the 15 patients with no GI symptoms, 5 were found to have posterior compartment DE.

Conclusion:

In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than three times the odds of having DE of the posterior compartment on MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DE.

Magnetic resonance imaging for deep infiltrating endometriosis: current concepts, imaging technique and key findings

Endometriosis is an estrogen-dependent chronic disease affecting about 10% of reproductive-age women with symptoms like pelvic pain and infertility. Pathologically, it is defined by the presence of endometrial tissue outside the uterine cavity responsible for a chronic inflammatory process. For decades the diagnosis of endometriosis was based on surgical exploration and biopsy of pelvic lesions. However, laparoscopy is not a risk-free procedure with possible false negative diagnosis due to an underestimate of retroperitoneal structures such as ureters and nerves. For these reasons nowadays, the diagnosis of endometriosis is based on a noninvasive approach where clinical history, response to therapy and imaging play a fundamental role. Trans-vaginal ultrasound and magnetic resonance imaging are suitable for recognizing most of endometriotic lesions; nevertheless, their accuracy is strictly determined by operators’ experience and imaging technique. This review paper aims to make radiologists aware of the diagnostic possibilities of pelvic MRI and familial with the MR acquisition protocols and image interpretation for women with endometriosis.

Outcome after surgery for deep endometriosis infiltrating the rectum

OBJECTIVE

To evaluate the rate of postoperative complications between conservative surgery and segmental resection in patients with rectal endometriosis.

DESIGN

Single-center retrospective study.

SETTING

University hospital.

PATIENT(S)

A total of 232 women undergoing surgery for deep endometriosis infiltrating the rectum up to 15 cm from the anus with at least involvement of the muscularis layer, stratified into two arms according to surgical technique. Subgroup analysis was performed in patients without previous therapeutic laparoscopy for endometriosis (n = 108). A propensity-score approach was used to correct for group differences.

INTERVENTION(S)

All patients underwent CO₂-laser laparoscopic surgery: 61 underwent conservative surgery, and 171 had a segmental resection.

MAIN OUTCOME MEASURE(S)

Postoperative complication rate (Clavien-Dindo classification).

RESULT(S)

Clavien-Dindo type 1 and 2 complications did not differ between both groups. Clavien-Dindo type 3 complications were more frequent in the segmental resection group (1/61 [1.6%] conservative vs. 18/171 [10.5%] segmental), after propensity analysis only a trend was retained. In the subgroup analysis, no difference or trend was found (1/27 [3.7%] conservative vs. 5/81 [6.2%] segmental). A low rate of temporary diverting stoma was recorded: 24/232 (10.3%).

CONCLUSION(S)

A higher major complication (Clavien-Dindo ≥3) rate for segmental resections compared with conservative surgical treatment was shown in the overall population, although after correction for group differences this was attenuated to a trend only. However, in patients without previous therapeutic laparoscopy no significant difference or trend was found regardless of the surgical technique used. This not only suggests that redo/repeated surgery has a potentially increased morbidity, but also emphasizes the importance of a well executed primary surgery.