Optimal imaging modality for detection of rectosigmoid deep endometriosis: systematic review and meta-analysis

ACR Appropriateness Criteria® Endometriosis

Endometriosis is a common condition impacting individuals assigned female at birth. Though incompletely understood, the disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis. Clinical presentation is variable, ranging from asymptomatic to severe pelvic pain and infertility. Treatment is determined by the patient's individualized goals and can include medical therapies to temporize symptoms or definitive surgical excision. Imaging is used to help diagnose endometriosis and for treatment planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting

Endometriosis is a common condition impacting approximately 190 million individuals and up to 50% of women with infertility globally. The disease is characterized by endometrial-like tissue located outside of the uterine corpus, which causes cyclical hemorrhage, inflammation, and fibrosis. Based on clinical suspicion or findings at routine transvaginal pelvic US or other prior imaging, dedicated imaging for endometriosis may be warranted with MRI or advanced transvaginal US. Deep endometriosis (DE) in the pelvis includes evaluation for stromal and fibrotic components and architectural distortion resulting from fibrosis and tethering. It is a disease requiring a compartment-based, pattern-recognition approach. MRI has the benefit of global assessment of the pelvis and is effective in assessing for features of malignancy and for evaluating extrapelvic locations. Transvaginal US has the advantage of dynamic maneuvers to assess for adhesions and may achieve higher spatial resolution for assessing the depth of bowel wall invasion. T1-weighted MRI evaluation increases the specificity of diagnosis by identifying hemorrhagic components, but the presence of T1 signal hyperintensity is not essential for diagnosing DE. Endometriosis is a disease with a broad spectrum; understanding the mild through advanced manifestations, including malignancy evaluation, is within the scope and breadth of radiologists' interpretation.

Diagnostic performance of transvaginal sonography vs. magnetic resonance imaging for rectovaginal septum deep infiltrating endometriosis: a head-to-head comparative meta-analysis

AIM

We aimed to compare the diagnostic performance of transvaginal sonography (TVS) versus magnetic resonance imaging (MRI) in identifying deep infiltrating endometriosis (DIE) in the rectovaginal septum (RVS) of affected patients.

MATERIALS AND METHODS

An extensive search was conducted in the PubMed, Embase databases to identify available publications up to November 2023. Studies evaluating the diagnostic perfor-mance of TVS and MRI for DIE in patients with rectovaginal septum involvement were all included. Sensitivity and specificity analyses employed the DerSi-monian and Laird method, complemented by the Freeman-Tukey double arc-sine trans-formation. Additionally, the study quality was rigorously evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method.

RESULTS

The meta-analysis encompassed 8 articles with a total of 721 patients. It revealed that the overall sensitivity of TVS was 0.51 (95% CI: 0.31-0.72), contrasted with 0.74 (95% CI: 0.66-0.82) for MRI. This finding suggests a higher sensitivity of MRI compared to TVS (P=0.04). Conversely, the overall specificity was 0.97 (95%CI: 0.94-1.00) for TVS and 0.93 (95% CI: 0.84-0.99) for MRI, indicating a comparable level of specificity between the two modalities (P=0.22).

CONCLUSION

Our meta-analysis reveals that MRI exhibits higher sensitivity and comparable specificity to TVS in patients with DIE of the RVS. However, the limited number of articles included may affect the evidence of these results. Therefore, further d number of articles included may affect the evidence of these results. Therefore, further research with larger sample sizes and prospective designs is essential to validate these findings.

Surgical treatment of colorectal endometriosis: an updated review

PURPOSE OF REVIEW

This review aims to summarize recent literature on the surgical treatment of colorectal endometriosis.

RECENT FINDINGS

The last decade has seen a surge in the number of studies on bowel endometriosis, with a focus on preoperative evaluation, perioperative management, surgical approach, and surgical outcomes. Many of these studies have originated from large-volume referral centers with varying surgical approaches and philosophies. Colorectal surgery for endometriosis seems to have a positive impact on patient symptoms, quality of life, and fertility. However, these benefits must be weighed against a significant risk of postoperative complications and the potential for long-term bowel or bladder dysfunction, especially for more radical procedures involving the lower rectum. Importantly, most studies regarding surgical technique and outcomes have been limited by their observational design.

SUMMARY

The surgical management of bowel endometriosis is complex and should be approached by a multidisciplinary team. Methodical preoperative evaluation, including appropriate imaging, is vital for surgical planning and patient counseling. The decision to perform a more conservative or radical excision is nuanced and remains an area of controversy. High quality studies in the form of multicenter randomized controlled trials are needed before clear recommendations can be made.

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.

Transvaginal ultrasound with bowel preparation versus transvaginal ultrasound with bowel preparation and water contrast for diagnosing Recto-Sigmoid endometriosis. A systematic review and Meta-Analysis

Transvaginal ultrasound is effective in diagnosing endometriosis involving the rectosigmoid bowel. Some authors suggest enhanced detection of rectosigmoid involvement with bowel preparation. Conversely, conflicting views argue that bowel preparation may not improve diagnostic precision, yielding similar results to rectal water contrast. No existing meta-analysis compares these approaches. Our study aims to conduct a meta-analysis to evaluate the diagnostic performance of transvaginal ultrasound with bowel preparation, with and without rectal water contrast. Studies published between 2000 and 2023 were searched in PubMed, Scopus, Cochrane and Web of Science. From 561 citations, we selected nine studies to include in this meta-analysis. The study quality was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2). The mean prevalence of endometriosis rectosigmoid was 43.6% (range 17,56-76,66%) in the group with bowel preparation and 64,80% (50,0-83,60%) for the group with bowel preparation and rectal water contrast. Pooled sensitivity and specificity were 93% and 94% for bowel preparation and 92% and 95% and for bowel preparation with water contrast. We conclude that, there was no significant difference between performing transvaginal ultrasound with intestinal preparation with and without water contrast. In clinical practice, the absence of a significant difference between these methods should be taken into account when making recommendations.

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.

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.

Diagnostic value of endoscopic ultrasound in pelvic masses with bowel involvement

BACKGROUND

The diagnostic ability of endoscopic ultrasound (EUS) for intestinal infiltration by pelvic masses has aroused considerable interest in many oncological settings. This study aimed to evaluate the effectiveness of EUS in predicting colorectal invasion in patients with pelvic masses and compare its accuracy with that of other imaging methods, namely pelvic MRI and abdominal computed tomography (CT), in predicting intestinal involvement in patients with histologically confirmed colorectal invasion.

METHODS

A hundred and eighty-four female patients with histologically confirmed benign or malignant pelvic masses were enrolled in a retrospective-prospective study. All patients underwent EUS, pelvic MRI, and one or more of abdominal CT, transvaginal sonography, and colonoscopy examinations before surgery. The surgical and pathological results were used as the gold standard to evaluate the diagnostic accuracy of EUS for colorectal invasion of pelvic masses.

RESULTS

This study included 184 patients who underwent surgery, with the time between EUS and surgery ranging from 1 to 309 (mean, 13.2) days. The diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of EUS for benign and malignant pelvic masses infiltrating the intestine were 83.3, 97.8, 99.1, and 66.2%, respectively. The overall diagnostic accuracy was 87.0%.

CONCLUSIONS

EUS is a simple, noninvasive, reliable, and accurate technique for the preoperative diagnosis of pelvic masses infiltrating the intestine. The authors recommend the use of this technology by gynecologists, as well as its incorporation into the preoperative diagnostic process to determine the most suitable surgical method. This would help in avoiding unexpected situations and unnecessary resource wastage during surgery.

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.

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.

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.

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.

Measuring quality of reporting in systematic reviews of diagnostic test accuracy studies in medical imaging: comparison of PRISMA-DTA and PRISMA

OBJECTIVES

To compare the reporting quality measured by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy studies (PRISMA-DTA) vs the original PRISMA checklist for systematic reviews of diagnostic test accuracy studies in imaging and survey the use of PRISMA-DTA by researchers and endorsement by journals.

METHODS

Systematic reviews of DTA studies published in 2020 and 2021 in Quartile 1 and Quartile 3 medical imaging journals (defined by Journal Citation Reports) were identified through PubMed. The reporting of each systematic review was assessed using PRISMA-DTA, PRISMA-2009 and PRISMA-2020. The item scores and overall score were compared among the three checklists. We also examined checklist adoption by the included systematic reviews and surveyed checklist endorsement from author instructions of included journals.

RESULTS

A total of 173 systematic reviews from 66 journals were included. The use of PRISMA-DTA, compared with PRISMA-2009 and PRISMA-2020, identified more issues in the reporting of title (proportion of systematic reviews with proper reporting, 27.2% vs 98.8% vs 98.8%), abstract (39.3% vs 97.1% vs 64.7%), eligibility criteria (67.6% vs 94.2% vs 94.2%), search (28.9% vs 72.3% vs 28.9%), definitions for data extraction (14.5% vs 91.9% vs 91.9%), diagnostic accuracy measures (38.2% vs 93.6% vs 93.6%), synthesis of results (28.9% vs 89.6% vs 73.4%) and results of individual studies (40.5% vs 80.3% vs 80.3%). The overall median reporting score measured by PRISMA-DTA (72.0% (interquartile range (IQR), 66.7-77.8%)) was lower than that measured by PRISMA-2009 (88.9% (IQR, 84.0-92.6%)) and similar to that measured by PRISMA-2020 (74.1% (IQR, 66.7-77.8%)). Additionally, PRISMA-DTA was used by only 43 (24.9%) systematic reviews and endorsed by two (3.0%) journals. These trends remained consistent for reviews published in journals with diverse scientific impact.

CONCLUSIONS

The use of PRISMA-DTA may identify more reporting inadequacies compared with the original PRISMA checklists when assessing diagnostic test accuracy systematic reviews, especially in critical sections such as title, abstract and methods. However, this tool is not commonly used by researchers and is inadequately endorsed by imaging journals. Our findings suggest a strong need to use PRISMA-DTA for reporting of diagnostic test accuracy systematic reviews by authors and its endorsement by journals. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis

Gynecological ultrasonography plays a central role in the management of endometriosis. The rapid technical development as well as the currently increasing evidence for non-invasive diagnostic methods require an updated compilation of recommendations for the use of ultrasound in the management of endometriosis. The present work aims to highlight the accuracy of sonography for diagnosing and classifying endometriosis and will formulate the present list of key messages and recommendations. This paper aims to demonstrate the accuracy of TVS in the diagnosis and classification of endometriosis and to discuss the clinical applications and consequences of TVS findings for indication, surgical planning and assessment of associated risk factors. (1) Sophisticated ultrasound is the primary imaging modality recommended for suspected endometriosis. The examination procedure should be performed according to the IDEA Consensus. (2) Surgical intervention to confirm the diagnosis alone is not recommended. A preoperative imaging procedure with TVS and/or MRI is strongly recommended. (3) Ultrasound examination does not allow the definitive exclusion of endometriosis. (4) The examination is primarily transvaginal and should always be combined with a speculum and a bimanual examination. (5) Additional transabdominal ultrasonography may enhance the accuracy of the examination in case of extra pelvic disease, extensive findings or limited transvaginal access. (6) Sonographic assessment of both kidneys is mandatory when deep endometriosis (DE) and endometrioma are suspected. (7) Endometriomas are well defined by sonographic criteria. When evaluating the ovaries, the use of IOTA criteria is recommended. (8) The description of sonographic findings of deep endometriosis should be systematically recorded and performed using IDEA terminology. (9) Adenomyosis uteri has sonographically well-defined criteria (MUSA) that allow for detection with high sensitivity and specificity. MRI is not superior to differentiated skilled ultrasonography. (10) Classification of the extent of findings should be done according to the #Enzian classification. The current data situation proves the best possible prediction of the intraoperative situs of endometriosis (exclusive peritoneum) for the non-invasive application of the #Enzian classification. (11) Transvaginal sonographic examination by an experienced examiner is not inferior to MRI diagnostics regarding sensitivity and specificity in the prediction of the extent of deep endometriosis. (12) The major advantage of non-invasive imaging and classification of endometriosis is the differentiated planning or possible avoidance of surgical interventions. The recommendations represent the opinion of experts in the field of non-invasive and invasive diagnostics as well as therapy of endometriosis. They were developed with the participation of the following national and international societies: DEGUM, ÖGUM, SGUM, SEF, AGEM/DGGG, and EEL.

Endometriosis: A multimodal imaging review

Endometriosis is a chronic inflammatory disorder characterized endometrial-like tissue present outside of the uterus, affecting approximately 10% of reproductive age women. It is associated with abdomino-pelvic pain, infertility and other non - gynecologic symptoms, making it a challenging diagnosis. Several guidelines have been developed by different international societies to diagnose and classify endometriosis, yet areas of controversy and uncertainty remains. Transvaginal ultrasound (TV-US) is the first-line imaging modality used to identify endometriosis due to its accessibility and cost-efficacy. Enhanced sonographic techniques are emerging as a dedicated technique to evaluate deep infiltrating endometriosis (DIE), depending on the expertise of the sonographer as well as the location of the lesions. MRI is an ideal complementary modality to ultrasonography for pre-operative planning as it allows for a larger field-of-view when required and it has high levels of reproducibility and tolerability. Typically, endometriotic lesions appear hypoechoic on ultrasonography. On MRI, classical features include DIE T2 hypointensity, endometrioma T2 hypointensity and T1 hyperintensity, while superficial peritoneal endometriosis (SPE) is described as a small focus of T1 hyperintensity. Imaging has become a critical tool in the diagnosis, surveillance and surgical planning of endometriosis. This literature review is based mostly on studies from the last two decades and aims to provide a detailed overview of the imaging features of endometriosis as well as the advances and usefulness of different imaging modalities for this condition.

Transvaginal Ultrasound in the Diagnosis and Assessment of Endometriosis-An Overview: How, Why, and When

Endometriosis is a common gynaecological disease, causing symptoms such as pelvic pain and infertility. Accurate diagnosis and assessment are often challenging. Transvaginal ultrasound (TVS), along with magnetic resonance imaging (MRI), are the most common imaging modalities. In this narrative review, we present the evidence behind the role of TVS in the diagnosis and assessment of endometriosis. We recognize three forms of endometriosis: Ovarian endometriomas (OMAs) can be adequately assessed by transvaginal ultrasound. Superficial peritoneal endometriosis (SUP) is challenging to diagnose by either imaging modality. TVS, in the hands of appropriately trained clinicians, appears to be non-inferior to MRI in the diagnosis and assessment of deep infiltrating endometriosis (DIE). The IDEA consensus standardized the terminology and offered a structured approach in the assessment of endometriosis by ultrasound. TVS can be used in the non-invasive staging of endometriosis using the available classification systems (rASRM, #ENZIAN). Given its satisfactory overall diagnostic accuracy, wide availability, and low cost, it should be considered as the first-line imaging modality in the diagnosis and assessment of endometriosis. Modifications to the original ultrasound technique can be employed on a case-by-case basis. Improved training and future advances in ultrasound technology are likely to further increase its diagnostic performance.

Differences in intensity and quality of bowel symptoms in patients with colorectal endometriosis : An observational cross-sectional study

BACKGROUND

Patients suffering from colorectal deep endometriosis (DE) experience gastrointestinal symptoms with almost the same frequency as gynecological pain symptoms. Preoperatively existing gastrointestinal symptoms may translate into pathological gastrointestinal quality of life index (GIQLI) and low anterior resection syndrome scores (LARS). This prospective questionnaire-based case control study aims to assess the prevalence of gastrointestinal complaints reflected by changes in LARS and GIQLI scores in patients with colorectal deep endometriosis prior to surgical treatment and compare those to a healthy control group.

METHODS

The study was conducted at the Hospital St. John of God in Vienna and included a total of 97 patients with histologically confirmed colorectal DE with radical surgical treatment and 96 women in whom DE was excluded via transvaginal sonography (TVS) or visually. Gastrointestinal symptoms reflected by LARS and GIQLI scores were evaluated presurgically and in controls.

RESULTS

A total of 193 premenopausal patients were included in this study. A mean GIQLI of 90.7 ± 22.0 and 129.4 ± 11.1 was observed among patients and controls, respectively, showing a significantly higher morbidity concerning gastrointestinal symptoms and decreased quality of life (QoL) compared to healthy controls (p < 0.001). The LARS score results demonstrated that 18.6% of the patients with bowel DE presented with a major LARS and 27.8% with a minor LARS presurgically compared to 2.1% and 9.4% of control patients, respectively (p < 0.001).

CONCLUSION

Patients with colorectal DE experience a quality of gastrointestinal symptoms translating into a decreased QoL and pathological GIQLI and LARS scores already presurgically. As a consequence, these instruments should be interpreted with caution.

Effectiveness of ultrasound for endometriosis diagnosis

PURPOSE OF REVIEW

Endometriosis is a chronic benign gynaecological condition characterized by pelvic pain, subfertility and delay in diagnosis. There is an emerging philosophical shift from gold standard histopathological diagnosis through laparoscopy to establishing diagnosis through noninvasive imaging.

RECENT FINDINGS

The ENZIAN classification system was updated in 2021 to be suitable for both diagnostic imaging and laparoscopy. The accuracy of transvaginal ultrasound (TVUS) in diagnosing endometriosis varies depending on location of the lesion. A recent international pilot study found that when ultrasound is performed in accordance with the IDEA consensus, a higher detection of deep endometriosis is seen, with an overall sensitivity of 88% and specificity of 79% compared with direct surgical visualization.

SUMMARY

Although ultrasound can detect adenomyosis, deep endometriosis and endometriomas, it is not possible to reliably detect superficial endometriosis. In the instance of a negative ultrasound with persistence of symptoms despite medical therapy, laparoscopy should be considered for diagnosis and treatment.

Diagnostic accuracy of transvaginal ultrasound for detection of endometriosis using International Deep Endometriosis Analysis (IDEA) approach: prospective international pilot study

OBJECTIVE

To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in predicting deep endometriosis (DE) following the International Deep Endometriosis Analysis (IDEA) consensus methodology.

METHODS

This was an international multicenter prospective diagnostic accuracy study involving eight centers across six countries (August 2018-November 2019). Consecutive participants with endometriosis suspected based on clinical symptoms or historical diagnosis of endometriosis were included. The index test was TVS performed preoperatively in accordance with the IDEA consensus statement. At each center, the index test was interpreted by a single sonologist. Reference standards were: (1) direct visualization of endometriosis at laparoscopy, as determined by a non-blinded surgeon with expertise in endometriosis surgery; and (2) histological assessment of biopsied/excised tissue. Surgery was performed within 12 months following the index TVS. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios (LR+ and LR-) of TVS in the diagnosis of DE were calculated.

RESULTS

Included in the study were 273 participants with complete clinical, TVS, laparoscopic and histological data. Of these, based on histology, 256 (93.8%) were confirmed to have endometriosis, including superficial endometriosis, and 190 (69.6%) were confirmed to have DE. Based on surgical visualization, 207/273 (75.8%) patients had DE. For DE overall, the diagnostic performance of TVS based on surgical visualization as the reference standard was as follows: accuracy, 86.1%; sensitivity, 88.4%; specificity, 78.8%; PPV, 92.9%; NPV, 68.4%; LR+, 4.17; LR-, 0.15, and the diagnostic performance of TVS based on histology as the reference standard was as follows: accuracy, 85.9%; sensitivity, 89.8%; specificity, 75.9%; PPV, 90.4%; NPV, 74.6%; LR+, 3.72; LR-, 0.13.

CONCLUSIONS

Using the IDEA consensus methodology provides strong diagnostic accuracy for TVS assessment of DE. We found a higher TVS detection rate of DE overall than that reported by the most recent meta-analysis on the topic (sensitivity, 79%), albeit with a lower specificity. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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.

What is the accuracy of transvaginal ultrasound for endometriosis mapping prior to surgery when performed by a sonographer within an outpatient women's imaging centre?

INTRODUCTION

This study aimed to assess the accuracy of transvaginal ultrasound (TVUS) for the mapping of endometriosis before surgery when performed by sonographers in an outpatient women's imaging centre.

METHODS

A prospective longitudinal cohort study was performed. The study group comprised of 201 women who underwent a comprehensive TVUS assessment, performed by a sonographer. Laparoscopy was performed as the reference standard. Complete TVUS and surgical data were available for 53 women who were included in the final analysis.

RESULTS

Endometriosis was confirmed at a surgery in 50/53 (94.3%) participants, with 25/53 (47.2%) having deep endometriosis (DE) nodules and/or endometriomas present. TVUS for mapping of DE had an overall sensitivity of 84.0%, specificity of 89.3%, PPV of 87.5%, NPV of 86.2%, LR+ of 7.85, LR- of 0.18, and accuracy of 86.8% (P < 0.001). Ovarian immobility had poor sensitivity for detecting localised superficial endometriosis, DE, adhesions, and/or endometriomas (Left = 61.9% and right = 13.3%) but high specificities (left = 87.5% and right = 94.7%). Site-specific tenderness had low sensitivities and moderate specificities for the same. All soft markers of endometriosis failed to reach statistical significance except for left ovarian immobility (P = <0.001).

CONCLUSION

Sonographers well experienced in obstetric and gynaecological imaging, working in an outpatient women's imaging setting can accurately map DE; however, the performance of soft markers for detection of SE was poor.

AN ULTRASOUND-BASED PREDICTION MODEL TO PREDICT URETEROLYSIS AT LAPAROSCOPIC ENDOMETRIOSIS SURGERY

STUDY OBJECTIVES

To develop a model, including clinical features and ultrasound findings, to predict the need for ureterolysis (i.e. dissection of the ureter) during laparoscopy for endometriosis.

DESIGN

A retrospective observational study of patients who had transvaginal ultrasound (TVS) according to the International Deep Endometriosis Analysis (IDEA) consensus and subsequent laparoscopy +/- excision of endometriosis between January 2017 and February 2021 was conducted.

SETTING

Sydney Medical School Nepean, University of Sydney, Nepean Hospital and Blue Mountains Hospital, New South Wales, Australia INTERVENTION: The demographic, clinical, TVS and intra-operative data were extracted through electronic clinical records.

MEASUREMENTS

Multi-categorical decision-tree and baseline models were built to choose the variables most correlated to the outcome under study. Receiver operating characteristic (ROC) analysis was performed on the binary classification. Based on our results, we selected the variables performing with significant statistical differences (p-value < .05).

MAIN RESULTS

During the study period, 177 consecutive patients were recruited and divided into two subgroups, ureterolysis (51.4%) and and non-ureterolysis (48.6%). Ureterolysis was noted in 87.5% of patients in which the left ovary was immobile (p-value< .001), and in 82.5% in which the right ovary was fixed (p-value<.001). For patients with right uterosacral ligament (USL) deep endometriosis (DE), ureterolysis was performed on 96.2% (p-value< .001), and 64.6% (p-value= .043) for left USL DE. Among patients with bowel DE, the proportion of patients undergoing ureterolysis was 95.5% (p-value < .001). The prognostic variables utilized in the final model to predict ureterolysis included dyschezia, absence of ovarian mobility, presence of right or left USL DE and presence of bowel DE on TVS. According to the developed model, the baseline risk for performing ureterolysis is 20% in our sample. The overall model performance demonstrated an area under the ROC curve 0.82.

CONCLUSION

Our study demonstrates that it is possible to predict the need for ureterolysis with clinical and sonographic data. Furthermore, patients presenting with the combination of the variables of our model (dyschezia, ovarian immobility, USL and bowel DE lesions) have a high risk of ureterolysis. On the other hand, patients without these features have a low risk (approximately 20%) of needing ureterolysis.

'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis

Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.

Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study

OBJECTIVE

To compare the preoperative detection of endometriosis using transvaginal sonography (TVS) supplemented by transabdominal sonography (TAS) with surgical assessment of disease, using the #Enzian classification for endometriosis.

METHODS

This was a prospective multicenter diagnostic accuracy study of women undergoing TVS/TAS and radical surgery for deep endometriosis (DE) at different tertiary referral centers. The localization and grade of severity of the endometriotic lesions and adhesions were described according to the criteria of the #Enzian classification, both at preoperative ultrasound examination and during surgery. According to the #Enzian classification, the small pelvis is divided into three compartments for DE: A (rectovaginal septum and vagina); B (uterosacral and cardinal ligaments, parametrium and pelvic sidewalls); and C (rectum). In addition, further locations (F) are classified as adenomyosis (FA), urinary bladder involvement (FB) and ureteric involvement with signs of obstruction (FU). Other intestinal locations (FI) and other extragenital locations (FO) are also included. Ovarian endometriosis and adhesions at the level of the tubo-ovarian unit are listed as O and T, respectively. The #Enzian grade of severity (Grade 1-3) was determined for #Enzian compartments O, T, A, B and C based on the size of the lesion or the severity of the adhesions. Concordance between preoperative assessment using TVS/TAS and evaluation at surgery was assessed. The sensitivity, specificity, positive and negative predictive values and accuracy of TVS/TAS in the detection of endometriotic lesions/adhesions in the different #Enzian compartments were calculated.

RESULTS

In total, 745 women were included in the analysis. Preoperative TVS/TAS and surgical findings showed a concordance rate ranging between 86% and 99% for the presence or absence of endometriotic lesions/adhesions, depending on the evaluated #Enzian compartment. The concordance rate between TVS and surgery ranged between 71% and 92% for different severity grades, in #Enzian compartments O, T, A, B and C. Determining the presence or absence of adhesions at the level of the tubo-ovarian unit and classifying them accurately as Grade 1, 2 or 3 on TVS was more difficult than determining the presence and severity of endometriotic lesions in #Enzian compartments O, A, B and C. The sensitivity of TVS/TAS for the detection of endometriotic lesions ranged from 50% (#Enzian compartment FI) to 95% (#Enzian compartment A), specificity from 86% (#Enzian compartment T_left ) to 99% (#Enzian compartment FI) and 100% (#Enzian compartments FB, FU and FO), positive predictive value from 90% (#Enzian compartment T_right ) to 100% (#Enzian compartment FO), negative predictive value from 74% (#Enzian compartment B_left ) to 99% (#Enzian compartments FB and FU) and accuracy from 88% (#Enzian compartment B_right ) to 99% (#Enzian compartment FB).

CONCLUSIONS

The localization and severity of endometriotic lesions/adhesions, as described and classified according to the #Enzian classification, can be diagnosed accurately and non-invasively using TVS/TAS. The #Enzian classification provides a uniform classification system for describing endometriotic lesions, which can be used both at TVS/TAS and during surgical evaluation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Spiders and mushrooms: Reporting bowel endometriosis shape on preoperative MRI to flag surgical complexity

INTRODUCTION

Preoperative imaging of patients with endometriosis allows adequate counselling, referral to appropriate centres of expertise and workforce planning. The objective of this study was to assess the feasibility of simplified three-category preoperative endometriosis MRI morphological descriptors to predict subsequent surgical management.

METHODS

A single-centre observational study in 76 patients (median age 38 years, range 18-55) with preoperative endometriosis mapping MRI between 1 Jan 2015 and 31 Dec 2019. MRI studies were prospectively re-read blind-to-surgical outcome to categorise rectosigmoid morphology as normal, spider-shaped (linear T2-dark fibrotic bands) superficial endometriosis or typical crescentic or mushroom-shaped deep infiltrating endometriosis (DIE). Bowel motility was similarly categorised as normal, tethered or distorted/fixed. The reference standard was subsequent surgery within 3 years of MRI, categorised as no bowel surgery, adhesiolysis only or more complex surgeries.

RESULTS

Despite three-quarters of surgical cases having normal bowel morphology on preoperative MRI (72%, 55/76; 12% linear superficial endometriosis, 10% crescentic and 5% mushroom-shaped DIE) more than half showed bowel tethering (54%, 41/76) or distortion/fixation (10%, 8/76) and most patients underwent adhesiolysis (79%, 60/76). Complex surgery such as bowel resection, laparotomy conversion or complex adhesiolysis is predicted by morphology (crescentic or mushroom-shaped DIE, P < 0.001) and motility (tethered or distorted bowel, P = 0.002) descriptors.

CONCLUSIONS

Comprehensive and clinically relevant diagnostic reporting does not have to be convoluted to have clinical impact: in our study population, categorising bowel morphology as normal, spider-shaped (superficial) or crescentic/mushroom-(DIE) shaped and motility as normal, tethered (superficial) or distorted/fixed (deep endometriosis) correlates to subsequent surgical complexity.

How long does a transvaginal ultrasound examination for endometriosis take in comparison to a routine transvaginal ultrasound examination?

INTRODUCTION

This study aimed to determine the additional time needed to perform an endometriosis transvaginal ultrasound (eTVUS) compared to routine transvaginal ultrasound (rTVUS).

METHODS

A retrospective case-control study was performed. The study group included 199 eTVUS performed between September 2019 and September 2020. The control group comprised 105 consecutive rTVUS studies performed in the same time period. The time stamps on the ultrasound images of all cases in both groups were reviewed to determine the time taken to perform each study. Mean, median, minimum and maximum scan times for both groups were calculated as was percentage difference between scan times. A two-tailed, unpaired t-test of the normalised data and a Mann-Whitney U test assessing time difference of scans between two groups were performed with P value <0.05 considered statistically significant.

RESULTS

Performing eTVUS took significantly longer than rTVUS with increases in the mean (8.4 vs 13.8 min, 64%), median (7 vs 12 min, 71%), minimum (4 vs 7 min, 75%) and maximum (19 vs 42 min, 121%) scan times. The Mann-Whitney U test indicated a statistically significant difference in the median scan times (5.0, CI 4.0-6.0), P < 0.001. An independent t-test of the normalised data revealed a significantly larger mean scan time for eTVUS than rTVUS, Mean = 9.05 95%CI [13.17-4.94], t(302) = 4.327, P < 0.001. R 2 = 0.583.

CONCLUSION

Endometriosis transvaginal ultrasound added an average 5.4 min to rTVUS, which is statistically significant. For ultrasound departments wanting to offer this technique, doubling the scan time allocated to perform a transvaginal ultrasound (TVUS) is suggested.

The Reproducibility of Ultrasonographic Findings of Rectosigmoid Endometriosis Among Examiners With Different Level of Expertise

OBJECTIVE

To analyze the reproducibility of ultrasonographic (US) findings of rectosigmoid endometriosis among examiners with different level of expertise using stored three-dimensional (3D) volumes of the posterior compartment of the pelvis as a part of SANABA (Sardinia-Navarra-Barcelona) collaborative study.

MATERIALS AND METHODS

Six examiners in 3 academic Department of Obstetrics and Gynecology, with different levels of experience and blinded to each other, evaluated 60 stored 3D volumes from the posterior compartment of the pelvis and looked for the presence or absence of features of rectosigmoid endometriotic lesions defined as an irregular hypoechoic nodule with or without hypoechoic foci at the level of the muscularis propria of the anterior wall rectum sigma. Multiplanar view and virtual navigation were used. All examiners had to assess the 3D volume of posterior compartment of the pelvis and classify it as present or absent disease. To analyze intra-observer and the inter-observer agreements, each examiner performed the assessment twice with a 2-week interval between the first and second assessments. Reproducibility was assessed by calculating the weighted Kappa index.

RESULTS

Intra-observer reproducibility was moderate to very good for all observers (Kappa index ranging from 0.49 to 0.96) associated with a good diagnostic accuracy of each reader. Inter-observer reproducibility was fair to very good (Kappa index range: 0.21-0.87).

CONCLUSIONS

The typical US sign of rectosigmoid endometriosis is reasonably recognizable to observers with different level of expertise when assessed in stored 3D volumes.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of uterosacral ligaments/torus uterinus, rectovaginal septum and vaginal deep endometriosis

STUDY QUESTION

Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis?

SUMMARY ANSWER

The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent.

WHAT IS KNOWN ALREADY

The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis.

STUDY DESIGN SIZE DURATION

A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology.

PARTICIPANTS/MATERIALS SETTING METHODS

All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32-82%) and 95% (95% CI 90-98%), respectively, and for all MRI techniques were 81% (95% CI 66-90%) and 83% (95% CI 62-94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30-80%) and 100% (95% CI 92-100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29-74%) and 98% (95% CI 95-99%), respectively, and for all MRI techniques were 64% (95% CI 40-83%) and 98% (96% CI 93-99%). Pooled analyses were not possible for other imaging modalities.

LIMITATIONS REASONS FOR CAUTION

There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease.

WIDER IMPLICATIONS OF THE FINDINGS

MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women's and Children's Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics.

REGISTRATION NUMBER

Prospective registration with PROSPERO (CRD42017059872) was obtained.

A prospective study comparing rectal water contrast-transvaginal ultrasonography with sonovaginography for the diagnosis of deep posterior endometriosis

INTRODUCTION

Preoperative assessment of deep endometriotic (DE) nodules is necessary to inform patients about the possible treatments and provide informed consent in case of surgery. This study aims to investigate the diagnostic performance of rectal water-contrast transvaginal ultrasonography (RWC-TVS) and sonovaginography (SVG) in women with suspicion of posterior DE.

MATERIAL AND METHODS

This prospective comparative study (NCT04296760) enrolled women with clinical suspicion of DE at our institution (Piazza della Vittoria 14 SRL, Genoa, Italy). Exclusion criteria were previous diagnosis of DE by imaging techniques or laparoscopy. All patients underwent RWC-TVS and SVG, independently performed by two gynecological sonologists blinded to the other technique's results. Patients underwent laparoscopic surgery within the following three months; imaging findings were compared with surgical and histological results.

RESULTS

In 208 of 281 (74.0%) patients included, posterior DE was surgically confirmed in rectosigmoid (n = 88), vagina (n = 21), rectovaginal septum (n = 34) and uterosacral ligaments (n = 156). RWC-TVS and SVG demonstrated similar sensitivity (SE; 93.8% vs 89.4%; p = 0.210) and specificity (SP; 86.3% vs 79.4%; p = 0.481) in diagnosing posterior DE. Specifically, both examinations had similar accuracy in detecting nodules of uterosacral ligaments (p = 0.779), vagina (p = 0.688) and rectovaginal septum (p = 0.824). RWC-TVS had higher SE (95.2% vs 82.0%; p = 0.003) and similar SP (99.5% vs 98.5%; p = 0.500) in diagnosing rectosigmoid endometriosis and estimated better infiltration of intestinal submucosa (p = 0.039), and distance between these nodules and anal verge (p < 0.001); only RWC-TVS allowed the estimation of bowel lumen stenosis. A similar proportion of discomfort was experienced during both examinations (p = 0.191), although a statistically higher mean visual analog score was reported during RWC-TVS (p < 0.001).

CONCLUSIONS

Although RWC-TVS and SVG have similar accuracy in the diagnosis of DE, RWC-TVS performed better in assessment of the characteristics of rectosigmoid endometriosis.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis

OBJECTIVE

To review the diagnostic accuracy and determine the optimum imaging modality for the detection of bladder deep endometriosis (DE) in women with a clinical suspicion of endometriosis.

METHODS

A systematic review of studies published from inception to May 2020 using Embase, Google Scholar, Medline, PubMed and Scopus. Prospective studies, which pre-operatively assessed any imaging modality for the presence of bladder DE, and correlated with the gold standard surgical data as a reference were included. The QUADAS-2 tool was used to assess quality. This review was prospectively registered with PROSPERO (CRD42017059872).

RESULTS

Of the 1,977 references identified, 8 studies (n = 1,052) were included in the analysis. The overall pooled sensitivity and specificity, from which the likelihood ratio of a positive test (LR+), likelihood ratio of a negative test (LR-) and diagnostic odds ratio (DOR) were calculated, for all transvaginal ultrasonography (TVS) techniques were 55 % (95 % CI 28-79%), 99 % (95 % CI 98-100%), 54.5 (95 % CI 18.9-157.4), 0.46 (95 % CI 0.25 - 0.85) and 119 (95 % CI 24-577), and for only two-dimensional (2D) TVS 53 % (95 % CI 23-82%), 99 % (96 % CI 97-100%), 48.8 (95 % CI 13.1-181.4), 0.47 (95 % CI 0.23 - 0.98), and 104 (95 % CI 15-711), respectively. Meta-analyses of the other modalities, namely magnetic resonance imaging (MRI) and transrectal endoscopic sonography (RES), were not possible due to the limited number of studies. There was significant heterogeneity and the studies were considered poor methodologically according to the QUADAS-2 tool.

CONCLUSIONS

Whilst the sensitivity of TVS was limited, the specificity was excellent. Given that there is a paucity of literature for other imaging modalities, until more studies are performed, TVS should be considered as the first-line tool given it is the only modality with sufficient evidence.

The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis

Advances in preoperative diagnostics as well as in surgical techniques for the treatment of endometriosis, especially for deep endometriosis, call for a classification system, that includes all aspects of the disease such as peritoneal endometriosis, ovarian endometriosis, deep endometriosis, and secondary adhesions. The widely accepted revised American Society for Reproductive Medicine classification (rASRM) has certain limitations because of its incomplete description of deep endometriosis. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable tool for staging deep endometriosis, but does not include peritoneal or ovarian disease or adhesions. To overcome these limitations, a comprehensive classification system for complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions and degree of involvement of the adjacent organs, that can be used with both diagnostic and surgical methods, has been created through a consensus process and will be described in detail-the #Enzian classification.

Comparison between Sonography-based and Surgical Extent of Deep Endometriosis Using the Enzian Classification - A Prospective Diagnostic Accuracy Study

STUDY OBJECTIVE

To compare a preoperative evaluation of deep endometriosis (DE) by transvaginal sonography (TVS) according to the Enzian classification with the intraoperatively assessed extent of DE using the Enzian system.

DESIGN

Prospective diagnostic accuracy study.

SETTING

Tertiary referral center for endometriosis.

PATIENTS

Women undergoing TVS and surgery for DE between 2017 and 2019 (N = 195).

INTERVENTIONS

Evaluation of DE lesion sizes according to the Enzian classification as evaluated by preoperative TVS compared with surgical findings.

MEASUREMENTS AND MAIN RESULTS

The rate of exact concordances between preoperative TVS-based predictions of DE lesion sizes and intraoperatively assessed lesion sizes according to the Enzian classification varied depending on anatomic localizations, that is, Enzian compartments, and evaluated lesion size. The highest rate of exact concordances was found in Enzian compartment C (rectosigmoid) in which 86% of all TVS C3 lesions were confirmed as such at surgery. Enzian compartment A (vagina, rectovaginal septum) showed similar results. The rates of exact concordances were slightly lower in Enzian compartment B (uterosacral ligaments, parametria), with confirmation at surgery of 71% of TVS B2 lesions. In most cases of discordant findings, an underestimation of the lesion size by 1 severity grade was observed compared with the intraoperative findings. In Enzian compartment FB (urinary bladder), 91% of the lesions seen at TVS and 98% of cases without any lesion at TVS were confirmed surgically. TVS could detect DE preoperatively in compartments A, B, C, and FB with an overall sensitivity of 84%, 91%, 92%, and 88%, respectively, and a specificity of 85%, 73%, 95%, and 99%, respectively.

CONCLUSION

TVS provides a valuable preoperative estimation of DE localization and lesion size using the Enzian classification, especially for Enzian compartments A, C, and FB. For Enzian compartment B, the exact assessment of the lesion size using the Enzian system seems to be less precise than for the other compartments.

Impact of Uterine Adenomyosis on Pregnancy Outcomes in Women Undergoing In Vitro Fertilization Treated With a Long-Term Pituitary Downregulation Protocol

BACKGROUND

Some studies have demonstrated that adenomyosis patients can achieve a comparable pregnancy outcome with women with normal uteruses, while there is no unanimous conclusion at present.

METHOD

We recruited 65 adenomyosis patients and 260 frequency-matched control women with endometriosis at a ratio of 1:4 according to age. Clinical pregnancy rate, spontaneous abortion rate, and live birth rate were compared between these two groups after controlling other factors.

RESULTS

Compared with endometriosis patients, adenomyosis patients had a higher antral follicle count (AFC) (12.71 vs 11.65, P=0.027). Though the two groups had the same number of embryos transferred, adenomyosis patients had an obviously declined implantation rate (31.91% vs 46.74%, P=0.005), clinical pregnancy rate (47.06% vs 64.42%, P=0.028), live birth rate (31.37% vs 54.81%, P=0.004), and significantly increased spontaneous abortion rate (33.33% vs 13.43%, P=0.034). Multivariate logistic regression analysis showed that adenomyosis had adverse influences on pregnancy outcome when age and the number of embryo transfers were controlled (adjusted OR=0.361, P=0.003).

CONCLUSION

Even after being matched with age, adenomyosis still had adverse influences on the pregnancy outcome of IVF in patients undergoing the long protocol.