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Ichikawa M, Shiraishi T, Okuda N, Matsuda S, Nakao K, Kaseki H, Ichikawa G, Akira S, Toyoshima M, Kuwabara Y, Suzuki S. Feasibility of Predicting Surgical Duration in Endometriosis Using Numerical Multi-Scoring System of Endometriosis (NMS-E). Biomedicines 2024; 12:1267. [PMID: 38927474 PMCID: PMC11201286 DOI: 10.3390/biomedicines12061267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/14/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Endometriosis is a multifaceted gynecological condition that poses diagnostic challenges and affects a significant number of women worldwide, leading to pain, infertility, and a reduction in patient quality of life (QoL). Traditional diagnostic methods, such as the revised American Society for Reproductive Medicine (r-ASRM) classification, have limitations, particularly in preoperative settings. The Numerical Multi-Scoring System of Endometriosis (NMS-E) has been proposed to address these shortcomings by providing a comprehensive preoperative diagnostic tool that integrates findings from pelvic examinations and transvaginal ultrasonography. METHODS This retrospective study aims to validate the effectiveness of the NMS-E in predicting surgical outcomes and correlating with the severity of endometriosis. Data from 111 patients at Nippon Medical School Hospital were analyzed to determine the correlation between NMS-E scores, including E-score-a severity indicator-traditional scoring systems, surgical duration, blood loss, and clinical symptoms. This study also examined the need to refine parameters for deep endometriosis within the NMS-E to enhance its predictive accuracy for disease severity. RESULTS The mean age of the patient cohort was 35.1 years, with the majority experiencing symptoms such as dysmenorrhea, dyspareunia, and chronic pelvic pain. A statistically significant positive correlation was observed between the NMS-E's E-score and the severity of endometriosis, particularly in predicting surgical duration (Spearman correlation coefficient: 0.724, p < 0.01) and blood loss (coefficient: 0.400, p < 0.01). The NMS-E E-score also correlated strongly with the r-ASRM scores (coefficient: 0.758, p < 0.01), exhibiting a slightly more excellent predictive value for surgical duration than the r-ASRM scores alone. Refinements in the methodology for scoring endometriotic nodules in uterine conditions improved the predictive accuracy for surgical duration (coefficient: 0.752, p < 0.01). CONCLUSIONS Our findings suggest that the NMS-E represents a valuable preoperative diagnostic tool for endometriosis, effectively correlating with the disease's severity and surgical outcomes. Incorporating the NMS-E into clinical practice could significantly enhance the management of endometriosis by addressing current diagnostic limitations and guiding surgical planning.
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Affiliation(s)
- Masao Ichikawa
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
- Department of Obstetrics and Gynecology, Nippon Medical School Chiba Hokuso Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan; (T.S.); (H.K.); (G.I.)
| | - Tatsunori Shiraishi
- Department of Obstetrics and Gynecology, Nippon Medical School Chiba Hokuso Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan; (T.S.); (H.K.); (G.I.)
| | - Naofumi Okuda
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
| | - Shigeru Matsuda
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
| | - Kimihiko Nakao
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
| | - Hanako Kaseki
- Department of Obstetrics and Gynecology, Nippon Medical School Chiba Hokuso Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan; (T.S.); (H.K.); (G.I.)
| | - Go Ichikawa
- Department of Obstetrics and Gynecology, Nippon Medical School Chiba Hokuso Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan; (T.S.); (H.K.); (G.I.)
| | - Shigeo Akira
- Meirikai Tokyo Yamato Hospital, 36-3 Honcho Itabashi, Tokyo 173-0001, Japan;
| | - Masafumi Toyoshima
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
| | - Yoshimitu Kuwabara
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
| | - Shunji Suzuki
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan; (N.O.); (S.M.); (K.N.); (M.T.); (Y.K.); (S.S.)
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Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis. Arch Gynecol Obstet 2023; 307:215-220. [PMID: 35239004 DOI: 10.1007/s00404-022-06451-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/10/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study is to investigate the correlation between the magnetic resonance imaging (MRI) and intraoperative findings of deep infiltrating endometriosis using the #ENZIAN score. METHODS This retrospective study included 64 patients who underwent surgery for deep infiltrating endometriosis between January 2017 and August 2020. Preoperative abdominopelvic MRI assessment was evaluated and scored using the #ENZIAN classification. Operative scores were considered the gold standard, and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of MRI for each category were calculated. RESULTS MRI has higher sensitivity and specificity in showing the lesions of the compartments O (ovarian lesions), A (rectovaginal septum and posterior vaginal fornix), and B (uterosacral ligaments and parametrium) (100-100%, 100-100%, and 97-100%, respectively, p < 0.001) compared to the other compartments. The lowest sensitivity, specificity, accuracy, and PPV of the MRI was found in compartment P (14%, 76%, 70%, and 7%, respectively). CONCLUSION We demonstrated that the #ENZIAN classification in MRI reports has significant sensitivity and specificity in compartments A, B (uterosacral ligaments and parametrium), and O. Furthermore, the determination of peritoneal lesions via MRI is inadequate.
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Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis. Arch Gynecol Obstet 2023; 307:5-19. [PMID: 36367580 PMCID: PMC9837004 DOI: 10.1007/s00404-022-06766-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022]
Abstract
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.
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Montanari E, Bokor A, Szabó G, Kondo W, Trippia CH, Malzoni M, Di Giovanni A, Tinneberg HR, Oberstein A, Rocha RM, Leonardi M, Condous G, Alsalem H, Keckstein J, Hudelist G. Comparison of #Enzian classification and revised American Society for Reproductive Medicine stages for the description of disease extent in women with deep endometriosis. Hum Reprod 2022; 37:2359-2365. [PMID: 36066464 DOI: 10.1093/humrep/deac187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/01/2022] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION How is endometriosis extent described by the #Enzian classification compared to the revised American Society for Reproductive Medicine (rASRM) stages in women undergoing radical surgery for deep endometriosis (DE)? SUMMARY ANSWER The prevalence and severity grade of endometriotic lesions and adhesions as well as the total number of #Enzian compartments affected by DE increase on average with increasing rASRM stage; however, DE lesions are also present in rASRM stages 1 and 2, leading to an underestimation of disease severity when using the rASRM classification. WHAT IS KNOWN ALREADY Endometriotic lesions can be accurately described regarding their localization and severity by sonography as well as during surgery using the recently updated #Enzian classification for endometriosis. STUDY DESIGN, SIZE, DURATION This was a prospective multicenter study including a total of 735 women between January 2020 and May 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS Disease extent in women undergoing radical surgery for DE at tertiary referral centers for endometriosis was intraoperatively described using the #Enzian and the rASRM classification. MAIN RESULTS AND THE ROLE OF CHANCE A total of 735 women were included in the study. Out of 31 women with rASRM stage 1, which is defined as only minimal disease, 65% (i.e. 20 women) exhibited DE in #Enzian compartment B (uterosacral ligaments/parametria), 45% (14 women) exhibited DE in #Enzian compartment A (vagina/rectovaginal septum) and 26% (8 women) exhibited DE in #Enzian compartment C (rectum). On average, there was a progressive increase from rASRM stages 1-4 in the prevalence and severity grade of DE lesions (i.e. lesions in #Enzian compartments A, B, C, FB (urinary bladder), FU (ureters), FI (other intestinal locations), FO (other extragenital locations)), as well as of endometriotic lesions and adhesions in #Enzian compartments P (peritoneum), O (ovaries) and T (tubo-ovarian unit). In addition, the total number of #Enzian compartments affected by DE lesions on average progressively increased from rASRM stages 1-4, with a maximum of six affected compartments in rASRM stage 4 patients. LIMITATIONS, REASONS FOR CAUTION Interobserver variability may represent a possible limitation of this study. WIDER IMPLICATIONS OF THE FINDINGS The #Enzian classification includes the evaluation of DE in addition to the assessment of endometriotic lesions and adhesions of the ovaries and tubes and may therefore provide a comprehensive description of disease localization and extent in women with DE. STUDY FUNDING/COMPETING INTEREST(S) No funding was received for this study. All authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Eliana Montanari
- Department of Gynecology, Center for Endometriosis, Hospital St. John of God, Vienna, Austria.,Department of Gynecology and Obstetrics, Medical University of Vienna, Vienna, Austria
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Gábor Szabó
- Department of Obstetrics and Gynecology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - William Kondo
- Department of Gynecology and Minimally Invasive Unit, Vita Batel Hospital, Curitiba, Brazil
| | | | - Mario Malzoni
- Endoscopica Malzoni, Centre for Advanced Pelvic Surgery, Avellino, Italy
| | | | | | - Anna Oberstein
- Department of Obstetrics and Gynecology, Nordwest Hospital, Frankfurt, Germany
| | - Rodrigo Manieri Rocha
- Acute Gynecology, Early Pregnancy and Advanced Endoscopy Surgery Unit, Nepean Hospital, Kingswood, NSW, Australia.,Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - Mathew Leonardi
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia.,Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - George Condous
- Acute Gynecology, Early Pregnancy and Advanced Endoscopy Surgery Unit, Nepean Hospital, Kingswood, NSW, Australia.,Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - Hanan Alsalem
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - Joerg Keckstein
- Stiftung Endometrioseforschung (SEF), Westerstede, Germany.,Gynecological Clinic Drs Keckstein, Villach, Austria
| | - Gernot Hudelist
- Department of Gynecology, Center for Endometriosis, Hospital St. John of God, Vienna, Austria.,Stiftung Endometrioseforschung (SEF), Westerstede, Germany.,Rudolfinerhaus Private Clinic, Vienna, Austria
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Kristine Aas-Eng M, Keckstein J, Condous G, Abrão MS, Hudelist G. Deep endometriosis: can surgical complexity and associated risk factors be evaluated with transvaginal sonography and classification systems? Eur J Obstet Gynecol Reprod Biol 2022; 276:204-206. [DOI: 10.1016/j.ejogrb.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 11/04/2022]
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Dirou C, Fondin M, Pabic EL, Moawad G, Dion L, Nicolas F, Duros S, Bauville E, Coiffic J, Pizzoferrato AC, Béraud E, Levêque J, Lavoué V, Nyangoh Timoh K. Association of Preoperative Enzian Score with Postoperative Fertility in Patients with Deep Pelvic Endometriosis. J Gynecol Obstet Hum Reprod 2022; 51:102408. [PMID: 35588972 DOI: 10.1016/j.jogoh.2022.102408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 03/12/2022] [Accepted: 05/12/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Endometriosis is a chronic inflammatory disease with a negative impact on fertility. The Enzian classification provides a precise description of deep pelvic endometriotic lesions, especially in the retroperitoneal area, from preoperative pelvic MRI scans. However, it is not known if it is correlated with postoperative fertility. STUDY OBJECTIVE To determine if there is an association between the preoperative Enzian score and postoperative fertility after deep pelvic endometriosis surgery. DESIGN We conducted a descriptive, retrospective study using information from the ENDOREN database. SETTING This was a retrospective study at the Department of Obstetrics and Gynecology at Rennes University Hospital (France) from January 2013 to May 2019 PATIENTS AND INTERVENTIONS: We used information from the ENDOREN database that included all women who underwent surgery for deep endometriosis and wish to conceive. This surgery was intended in a view to achieve a complete removal of endometriosis. MEASUREMENTS The Enzian score was calculated from preoperative MRI scans, and total, spontaneous, and after In Vitro Fertilization (IVF) live births and pregnancies outcomes were collected from the patients'computerized medical records. Univariate and multivariate analysis was performed. RESULTS Sixty-eight patients were included. The live-birth rate was 35% (24/68). According to the Enzian classification, 25 patients (35%) were classified in compartment A, 64 patients (94%) in compartment B, and 27 (40%) in compartment C. In multivariate analysis, positive predictor of live birth was single Enzian B score (OR=4.7[1.21; 18.81], p=0.03), negative predictors were uterine adenomyosis and a history of endometriosis surgery. In multivariate analysis, positive predictor of spontaneous live birth was EFI score ≥7 (OR =22.434; CI [1.138; 442.190]). In multivariate analysis, positive predictor was Enzian A score (OR=15.9[2.2; 114.7], p=0.006), and negative predictors was uterine adenomyosis and Enzian B score (OR=0.01[0; 0.495], p=0.02) for live birth after IVF. CONCLUSION The present retrospective study cannot strongly conclude about fertility and correlation with Enzian score because the groups are too small. However, it seems that when solely the compartment B is involved by endometriosis, complete full removal of endometriosis leads to better post-operative live births results. Other studies must be done to determine if Enzian classification based on preoperative pelvic MRI could be clinical value in the decision-making strategy for managing infertile patients with deep pelvic endometriosis.
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Affiliation(s)
- Charlotte Dirou
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France; University 1, Rennes, France
| | - Maxime Fondin
- Department of Radiology, Rennes University Hospital, France; University 1, Rennes, France
| | - Estelle Le Pabic
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France; University 1, Rennes, France
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA
| | - Ludivine Dion
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France; Rennes, University 1, IRSET, Rennes, France; University 1, Rennes, France
| | - Florence Nicolas
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France
| | - Solène Duros
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France
| | - Estelle Bauville
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France
| | - Jean Coiffic
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France
| | | | - Eugénie Béraud
- Department of Radiology, Rennes University Hospital, France
| | - Jean Levêque
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France; University 1, Rennes, France
| | - Vincent Lavoué
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France; Rennes, University 1, IRSET, Rennes, France; University 1, Rennes, France
| | - Krystel Nyangoh Timoh
- Department of Obstetrics and Gynecology, Rennes University Hospital, 16 boulevard de Bulgarie, Rennes, France; University 1, Rennes, France.
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Wetzk M, Grübling N, Forberger A, Klengel J, Kuhlmann JD, Wimberger P, Goeckenjan M. Diagnostic Benefit of the Detection of Mitotic Figures in Endometriotic Lesions. Geburtshilfe Frauenheilkd 2022; 82:85-92. [PMID: 35027863 PMCID: PMC8747893 DOI: 10.1055/a-1580-0601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/05/2021] [Indexed: 11/01/2022] Open
Abstract
Objectives Endometriosis is a chronic disease which is diagnosed by surgical intervention combined with a histological work-up. Current international and national recommendations do not require the histological determination of the proliferation rate. The diagnostic and clinical importance of the mitotic rate in endometriotic lesions still remains to be elucidated. Methods In this retrospective study, the mitotic rates and clinical data of 542 patients with histologically diagnosed endometriosis were analyzed. The mean patient age was 33.5 ± 8.0 (17 - 72) years, and the mean reproductive lifespan was 21.2 ± 7.8 (4 - 41) years. Patients were divided into two groups and patients' reproductive history and clinical endometriosis characteristics were compared between groups. The study group consisted of women with confirmed mitotic figures (n = 140, 25.83%) and the control group comprised women without proliferative activity according to their mitotic rates (n = 402, 74.27%). Results Women with endometriotic lesions and histologically confirmed mitotic figures were significantly more likely to have a higher endometriosis stage (p = 0.001), deep infiltrating endometriosis (p < 0.001), ovarian endometrioma (p = 0.012), and infertility (p = 0.049). A mitotic rate > 0 was seen significantly less often in cases with incidental findings of endometriosis (p = 0.031). The presence of symptoms and basic characteristics such as age, age at onset of menarche, reproductive lifespan and parity did not differ between the group with and the group without mitotic figures. Conclusion This study shows that a simple histological assessment of the mitotic rate offers additional diagnostic value for the detection of advanced stages of endometriosis. The possible role as a predictive marker for the recurrence of endometriosis or the development of endometriosis-associated cancer will require future study.
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Affiliation(s)
- Michelle Wetzk
- Department of Obstetrics and Gynecology, Technische Universität Dresden, Dresden, Germany
| | - Nannette Grübling
- Department of Obstetrics and Gynecology, Technische Universität Dresden, Dresden, Germany
| | - Almuth Forberger
- Institute for Pathology, Technische Universität Dresden, Dresden, Germany
| | - Jörg Klengel
- Department of Obstetrics and Gynecology, Technische Universität Dresden, Dresden, Germany
| | - Jan Dominik Kuhlmann
- Department of Obstetrics and Gynecology, Technische Universität Dresden, Dresden, Germany
| | - Pauline Wimberger
- Department of Obstetrics and Gynecology, Technische Universität Dresden, Dresden, Germany
| | - Maren Goeckenjan
- Department of Obstetrics and Gynecology, Technische Universität Dresden, Dresden, Germany
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Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis Classification, Staging and Reporting Systems: A Review on the Road to a Universally Accepted Endometriosis Classification. J Minim Invasive Gynecol 2021; 28:1822-1848. [PMID: 34690085 DOI: 10.1016/j.jmig.2021.07.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In the field of endometriosis, several classification, staging and reporting systems have been developed. Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice? DATA SOURCES A systematic PUBMED literature search was performed. Data were extracted and summarized. METHODS OF STUDY SELECTION na TABULATION, INTEGRATION AND RESULTS: Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. CONCLUSION Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated for the purpose for which they were developed. The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.
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Affiliation(s)
- Nathalie Vermeulen
- ESHRE, Central office (Dr. Vermeulen), Meerstraat 60, Grimbergen, BE 1852, Belgium
| | - Mauricio S Abrao
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia (Dr. Abrao), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil; Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Jon I Einarsson
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery (Dr. Einarsson), Boston, MA, USA
| | - Andrew W Horne
- University of Edinburgh, MRC Centre for Reproductive Health (Dr. Horne), QMRI, 49 Little France Crescent, Edinburgh, UK EH16 4TJ
| | - Neil P Johnson
- Repromed Auckland, 105 Remuera Road, Remuera, Auckland (Dr. Johnson), New Zealand 1050
| | - Ted T M Lee
- Magee Womens Hospital of UPMC, Department of Obstetrics, Gynecology and Reproductive Sciences (Dr. Lee), Pittsburgh, PA, USA
| | - Stacey Missmer
- Michigan State University College of Human Medicine, Department of Obstetrics, Gynecology and Reproductive Biology (Dr. Missmer), East Lansing, MI, USA; Harvard University T H Chan School of Public Health, Department of Epidemiology, Boston, MA, USA; World Endometriosis Research Foundation, WERF, London, UK
| | - John Petrozza
- Massachusetts General Hospital Fertility Center, Department of Obstetrics and Gynecology (Dr. Petrozza), Boston, MA, USA
| | - Carla Tomassetti
- University Hospital Leuven, Department of Obstetrics and Gynaecology, Leuven University Fertility Centre (Dr. Tomassetti), Leuven, Belgium
| | - Krina T Zondervan
- University of Oxford, Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health (Dr. Zondervan), Oxford, Oxfordshire, UK; University of Oxford, Wellcome Centre for Human Genetics, Oxford, Oxfordshire, UK
| | - Grigoris Grimbizis
- Medical School, Aristotle University of Thessaloniki (Dr. Grimbizis), 1st Dept Obstet Gynecol, Tsimiski 51 Street, Thessaloniki, Greece 54623
| | - Rudy Leon De Wilde
- Carl von Ossietzky Universitat Oldenburg, University Hospital for Gynecology (Dr. De Wilde), Oldenburg, Germany.
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Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification . Hum Reprod Open 2021; 2021:hoab025. [PMID: 34693032 PMCID: PMC8530712 DOI: 10.1093/hropen/hoab025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/11/2021] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice? SUMMARY ANSWER Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. WHAT IS KNOWN ALREADY In the field of endometriosis, several classification, staging and reporting systems have been developed. PARTICIPANTS/MATERIALS, SETTING, METHODS A systematic PUBMED literature search was performed. Data were extracted and summarized. MAIN RESULTS AND THE ROLE OF CHANCE Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. LARGE SCALE DATA NA. LIMITATIONS, REASONS FOR CAUTION The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. WIDER IMPLICATIONS OF THE FINDINGS It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working toward a universally accepted endometriosis classification. STUDY FUNDING/COMPETING INTEREST(S) The meetings and activities of the working group were funded by the American Association of Gynecologic Laparoscopists, European Society for Gynecological Endoscopy, European Society of Human Reproduction and Embryology and World Endometriosis Society. A.W.H. reports grant funding from the MRC, NIHR, CSO, Wellbeing of Women, Roche Diagnostics, Astra Zeneca, Ferring, Charles Wolfson Charitable Trust, Standard Life, Consultancy fees from Roche Diagnostics, AbbVie, Nordic Pharma and Ferring, outside the submitted work. In addition, A.W.H. has a patent Serum biomarker for endometriosis pending. N.P.J. reports personal fees from Abbott, Guerbet, Myovant Sciences, Vifor Pharma, Roche Diagnostics, outside the submitted work; he is also President of the World Endometriosis Society and chair of the trust board. S.M. reports grants and personal fees from AbbVie, and personal fees from Roche outside the submitted work. C.T. reports grants, non-financial support and other from Merck SA, non-financial support and other from Gedeon Richter, non-financial support from Ferring Pharmaceuticals, outside the submitted work and without private revenue. K.T.Z. reports grants from Bayer Healthcare, MDNA Life Sciences, Roche Diagnostics Inc, Volition Rx, outside the submitted work; she is also a Board member (Secretary) of the World Endometriosis Society and World Endometriosis Research Foundation, Research Advisory Board member of Wellbeing of Women, UK (research charity), and Chair, Research Directions Working Group, World Endometriosis Society. The other authors had nothing to disclose. TRIAL REGISTRATION NUMBER NA.
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Affiliation(s)
| | | | - Mauricio S Abrao
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.,Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jon I Einarsson
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew W Horne
- University of Edinburgh, MRC Centre for Reproductive Health, QMRI, Edinburgh, UK
| | | | - Ted T M Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Stacey Missmer
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, MI, USA.,Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, MA, USA.,World Endometriosis Research Foundation, WERF, London, UK
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital Fertility Center, Boston, MA, USA
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven University Fertility Centre, Leuven, Belgium
| | - Krina T Zondervan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford Endometriosis CaRe Centre, Oxford, Oxfordshire, UK.,University of Oxford, Wellcome Centre for Human Genetics, Oxford, UK
| | - Grigoris Grimbizis
- 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rudy Leon De Wilde
- Carl von Ossietzky Universitat Oldenburg, University Hospital for Gynecology, Oldenburg, Germany
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10
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Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification. Facts Views Vis Obgyn 2021; 13:305-330. [PMID: 34672508 PMCID: PMC9148706 DOI: 10.52054/fvvo.13.3.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background In the field of endometriosis, several classification, staging and reporting systems have been developed. However, endometriosis classification, staging and reporting systems that have been published and validated for use in clinical practice have not been systematically reviewed up to now. Objectives The aim of the current review is to provide a historical overview of these different systems based on an assessment of published studies. Materials and Methods A systematic Pubmed literature search was performed. Data were extracted and summarised. Results Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific and different purposes. There is still no international agreement on how to describe the disease. Studies evaluating different systems are summarised showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the Enzian system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. Conclusions Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. What is new? This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.
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11
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Widschwendter P, Köhler M, Friedl T, Ammann B, Janni W, Rhomberg C, Karner M, Beer M, De Gregorio A, Polasik A. Diagnosis of presence and extent of deep infiltrating endometriosis by preoperative MRI-improvement of staging accuracy by expert training. J Gynecol Obstet Hum Reprod 2021; 51:102236. [PMID: 34592437 DOI: 10.1016/j.jogoh.2021.102236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/30/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study evaluates the clinical utility of magnetic resonance imaging (MRI) for the determination of presence and extent of DIE with special emphasis on effects of MRI reporting training MATERIAL AND METHODS: Data from 80 patients with clinically suspected DIE presented at our certified endometriosis center between 2015 and 2018 were analyzed. For all patients an ENZIAN score (describing DIE related to individual anatomical localizations) was obtained based on the preoperative MRI findings. The intraoperatively determined ENZIAN score served as the reference for assessment of diagnostic performance of the MRI. RESULTS Overall, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of DIE by MRI were 76.9%, 53.3%, 87.7% and 34.8%, respectively. Analysis by compartment revealed a sensitivity, specificity, PPV and NPV of 59.5%, 88.2%, 86.2% and 63.9%, respectively, for compartment A, with similar values for compartment B, and 50.0%, 88.9%, 64.7% and 81.4%, respectively, for the less often affected compartment C. Expert training (n = 32 before, n = 48 after) led to a considerable increase in sensitivities for the overall detection of DIE (84.6% vs. 65.4%, p = 0.071) and for the detection of DIE in compartment A (71.4% vs. 35.7%, p = 0.026), compartment B (66.7% vs. 37.5%, p = 0.057) and compartment C (75.0% vs. 20.0%, p = 0.010), without significant loss in specificity (all p > 0.50). DISCUSSION After expert training, MRI has a good sensitivity with fair specificity regarding preoperative assessment of presence, location and extent of DIE.
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Affiliation(s)
- P Widschwendter
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075 Ulm, Germany; Department of Gynecology and Obstetrics, General Hospital Hall, Milserstrasse 10, 6060 Hall in Tirol, Austria
| | - M Köhler
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
| | - Twp Friedl
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
| | - B Ammann
- Department of Radiology, University Hospital Ulm, Albert Einstein Allee 23, 89081 Ulm, Germany
| | - W Janni
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
| | - C Rhomberg
- Department of Gynecology and Obstetrics, General Hospital Hall, Milserstrasse 10, 6060 Hall in Tirol, Austria
| | - M Karner
- Department of Radiology, General Hospital Bruneck, Spitalstraße 11, 39031 Bruneck, Italy
| | - M Beer
- Department of Radiology, University Hospital Ulm, Albert Einstein Allee 23, 89081 Ulm, Germany
| | - A De Gregorio
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
| | - A Polasik
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075 Ulm, Germany.
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12
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Can New ENZIAN Score 2020 Represent a Staging System Improving MRI Structured Report? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18199949. [PMID: 34639248 PMCID: PMC8508493 DOI: 10.3390/ijerph18199949] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/17/2021] [Accepted: 09/19/2021] [Indexed: 11/17/2022]
Abstract
Structured reporting systems for endometriotic disease are gaining a central role in diagnostic imaging: our aim is to evaluate applicability and the feasibility of the recent ENZIAN score (2020) assessed by MRI. A total of 60 patients with suspected tubo–ovarian/deep endometriosis were retrospectively included in our study according to the following criteria: availability of MR examination; histopathological results from laparoscopic or surgical treatment; patients were not assuming estro-progestin or progestin therapy. Three different readers (radiologists with 2-, 5-, and 20-years of experience in pelvic imaging) have separately assigned a score according to the ENZIAN score (revised 2020) for all lesions detected by magnetic resonance imaging (MRI). Our study showed a high interobserver agreement and feasibility of the recent ENZIAN score applied to MRI; on the other hand, our experience highlighted some limitations mainly due to MRI’s inability to assess tubal patency and mobility, as required by the recent score (2020). In view of the limitations which arose from our study, we propose a modified MRI-ENZIAN score that provides a complete structured reporting system, more suitable for MRI. The high interobserver agreement of the recent ENZIAN score applied to MRI confirms its validity as a complete staging system for endometriosis, offering a shared language between radiologists and surgeons.
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13
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Thomassin-Naggara I, Lamrabet S, Crestani A, Bekhouche A, Wahab CA, Kermarrec E, Touboul C, Daraï E. Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management. Hum Reprod 2021; 35:1589-1600. [PMID: 32619220 DOI: 10.1093/humrep/deaa103] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/12/2020] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION Is an MRI classification of deep pelvic endometriosis (DE) able to correctly predict the risk of DE surgery. SUMMARY ANSWER A new radiological classification, that we have called the deep pelvic endometriosis index (dPEI) classification, is accurate and reproducible to assess the extension of the disease in central and lateral compartments and well correlated with operating time, hospital stay duration and the risk of voiding dysfunction. WHAT IS KNOWN ALREADY Few imaging classifications are currently available to predict the extent of DE to help preoperative assessment of surgical outcomes and provide the patient with objective information about the risk of surgical complications. STUDY DESIGN, SIZE, DURATION Retrospective monocentric observational study was conducted between 01 January 2017 and 31 December 2018 and included 150 women (mean age = 34.5 years, 20-52 years) with DE on MRI and who subsequently underwent surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS Two radiologists independently graded the disease according to MRI-based Enzian classification (A (rectovaginal septum and vagina locations), B (uterosacral locations) and C (rectosigmoid locations)) and a new radiological classification, that we have called the dPEI, that grades the severity of DE as: mild, moderate or severe DE. MRI findings and classification were correlated with surgical and pathological results. MAIN RESULTS AND THE ROLE OF CHANCE MRI-based and surgical Enzian classifications were concordant for A lesions in 78.7% (118/150), for B lesions in 34.7% (52/150) and for C lesions in 82.7% (124/150). Operating time and hospital stays were longer in Group A2 (rectovaginal septum and vagina, 1-3 cm) compared to A0, B2 (uterosacral, 1-3 cm) compared to B0, C3 (rectosigmoid >3 cm) compared to C2 (rectosigmoid 1-3 cm) or C0 (P < 0.001), in severe compared to moderate DE patients, and in moderate compared to mild extensive patients (P < 0.01). Patients with vaginal or rectosigmoid involvement were respectively six and three times more likely to experience high-grade complications according to Clavien-Dindo classification than patients without vaginal or rectosigmoid disease (P < 0.001). Postoperative voiding dysfunction was correlated with A lesions (odds ratio (OR) = 6.82, 95% CI 2.34-20.5), moderate or severe DE (OR = 4.15, 95% CI 1.26-17.9), the presence of at least unilateral lateral pelvic involvement (OR = 3.6, 95% CI 1.14-11.2, P = 0.03) and C lesions (OR = 2.6, 95% CI 1.03-6.8, P < 0.01). LIMITATIONS, REASONS FOR CAUTION The study was conducted in an expert center and needs to be validated in a multicenter study. There is a limited number of patients with lateral pelvic endometriosis beyond the parietal fascia, probably due to the low prevalence of this disease presentation. WIDER IMPLICATIONS OF THE FINDINGS MRI imaging can be used to accurately predict postoperative complications for women with DE. This may help the clinician to preoperatively inform a patient about the risks of surgery. Larger clinical studies are required to validate these results. STUDY FUNDING/COMPETING INTEREST(S) No external funding was used for this study. I.T.N.: Remunerated lecture GE, Hologic, Guerbet, Canon; Advisory board: Siemens - These relationships are on the topic of breast imaging, not related to the topic of this paper. Other coauthors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Isabelle Thomassin-Naggara
- Sorbonne Université, IUC, 75005 Paris, France.,Department of Radiology, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - Samia Lamrabet
- Department of Radiology, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - Adrien Crestani
- Sorbonne Université, IUC, 75005 Paris, France.,Department of Gynaecology and Obstetrics, AP-HP, Hôpital Tenon, GRC-6 (Clinical Research Group on Endometriosis) Sorbonne University, UMRS-938, 75020 Paris, France
| | - Asma Bekhouche
- Sorbonne Université, IUC, 75005 Paris, France.,Department of Radiology, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - Cendos Abdel Wahab
- Sorbonne Université, IUC, 75005 Paris, France.,Department of Radiology, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - Edith Kermarrec
- Department of Radiology, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - Cyril Touboul
- Sorbonne Université, IUC, 75005 Paris, France.,Department of Gynaecology and Obstetrics, AP-HP, Hôpital Tenon, GRC-6 (Clinical Research Group on Endometriosis) Sorbonne University, UMRS-938, 75020 Paris, France
| | - Emile Daraï
- Sorbonne Université, IUC, 75005 Paris, France.,Department of Gynaecology and Obstetrics, AP-HP, Hôpital Tenon, GRC-6 (Clinical Research Group on Endometriosis) Sorbonne University, UMRS-938, 75020 Paris, France
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14
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Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, Krentel H, Janschek E, Exacoustos C, Malzoni M, Mueller M, Roman H, Condous G, Forman A, Jansen FW, Bokor A, Simedrea V, Hudelist G. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 2021; 100:1165-1175. [PMID: 33483970 DOI: 10.1111/aogs.14099] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/09/2020] [Accepted: 01/11/2021] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Jörg Keckstein
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Endometriosis Clinic Dres. Keckstein, Villach, Austria.,University of Ulm, Germany
| | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College Hospital, London, UK
| | - Uwe A Ulrich
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Endometriosis Center, Martin Luther Hospital, Berlin, Germany
| | - Martin Sillem
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Praxisklinik am Rosengarten, Mannheim, Germany.,Department of Obstetrics and Gynecology, Saarland University Medical School, Homburg, Germany
| | - Peter Oppelt
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department for Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Austria
| | - Karl W Schweppe
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany
| | - Harald Krentel
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Bethesda Hospital, Duisburg, Germany
| | - Elisabeth Janschek
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Villach General Hospital, Villach, Austria
| | - Caterina Exacoustos
- Department of Obstetrics and Gynecology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Malzoni
- Endoscopica Malzoni - Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy
| | - Michael Mueller
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - Horace Roman
- Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Sydney, Australia
| | - Axel Forman
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Frank W Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Voicu Simedrea
- Department of Obstetrics and Gynecology, Regina Maria Clinic, Timisoara, Romania
| | - Gernot Hudelist
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Gynaecology, Center for Endometriosis, Hospital St. John of God, Vienna, Austria
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15
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Metzemaekers J, Haazebroek P, Smeets MJGH, English J, Blikkendaal MD, Twijnstra ARH, Adamson GD, Keckstein J, Jansen FW. EQUSUM: Endometriosis QUality and grading instrument for SUrgical performance: proof of concept study for automatic digital registration and classification scoring for r-ASRM, EFI and Enzian. Hum Reprod Open 2020; 2020:hoaa053. [PMID: 33409380 PMCID: PMC7772248 DOI: 10.1093/hropen/hoaa053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/22/2020] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Is electronic digital classification/staging of endometriosis by the EQUSUM application more accurate in calculating the scores/stages and is it easier to use compared to non-digital classification? SUMMARY ANSWER We developed the first digital visual classification system in endometriosis (EQUSUM). This merges the three currently most frequently used separate endometriosis classification/scoring systems (i.e. revised American Society for Reproductive Medicine (rASRM), Enzian and Endometriosis Fertility Index (EFI)) to allow uniform and adequate classification and registration, which is easy to use. The EQUSUM showed significant improvement in correctly classifying/scoring endometriosis and is more user-friendly compared to non-digital classification. WHAT IS KNOWN ALREADY Endometriosis classification is complex and until better classification systems are developed and validated, ideally all women with endometriosis undergoing surgery should have a correct rASRM score and stage, while women with deep endometriosis (DE) should have an Enzian classification and if there is a fertility wish, the EFI score should be calculated. STUDY DESIGN SIZE DURATION A prospective endometriosis classification proof of concept study under experts in deep endometriosis was conducted. A comparison was made between currently used non-digital classification formats for endometriosis versus a newly developed digital classification application (EQUSUM). PARTICIPANTS/MATERIALS SETTING METHODS A hypothetical operative endometriosis case was created and summarized in both non-digital and digital form. During European endometriosis expert meetings, 45 DE experts were randomly assigned to the classic group versus the digital group to provide a proper classification of this DE case. Each expert was asked to provide the rASRM score and stage, Enzian and EFI score. Twenty classic forms and 20 digital forms were analysed. Questions about the user-friendliness (system usability scale (SUS) and subjective mental effort questionnaire (SMEQ)) of both systems were collected. MAIN RESULTS AND THE ROLE OF CHANCE The rASRM stage was scored completely correctly by 10% of the experts in the classic group compared to 75% in the EQUSUM group (P < 0. 01). The rASRM numerical score was calculated correctly by none of the experts in the classic group compared with 70% in the EQUSUM group (P < 0.01). The Enzian score was correct in 60% of the classic group compared to 90% in the EQUSUM group (P = 0.03). EFI scores were calculated correctly in 25% of the classic group versus 85% in the EQUSUM group (P < 0.01). Finally, the usability measured with the SUS was significantly better in the EQUSUM group compared to the classic group: 80.8 ± 11.4 and 61.3 ± 20.5 (P < 0.01). Also the mental effort measured with the SMEQ was significant lower in the EQUSUM group compared to the classic group: 52.1 ± 18.7 and 71.0 ± 29.1 (P = 0.04). Future research should further develop and confirm these initial findings by conducting similar studies with larger study groups, to limit the possible role of chance. LIMITATIONS REASONS FOR CAUTION These first results are promising, however it is important to note that this is a preliminary result of experts in DE and needs further testing in daily practice with different types (complex and easy) of endometriosis cases and less experienced gynaecologists in endometriosis surgery. WIDER IMPLICATIONS OF THE FINDINGS This is the first time that the rASRM, Enzian and EFI are combined in one web-based application to simplify correct and automatic endometriosis classification/scoring and surgical registration through infographics. Collection of standardized data with the EQUSUM could improve endometriosis reporting and increase the uniformity of scientific output. However, this requires a broad implementation. STUDY FUNDING/COMPETING INTERESTS To launch the EQUSUM application, a one-time financial support was provided by Medtronic to cover the implementation cost. No competing interests were declared. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- J Metzemaekers
- Department of Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
| | - P Haazebroek
- Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - M J G H Smeets
- Department of Gynaecology, Haaglanden Medisch Centrum-Bronovo, Den Haag, the Netherlands
| | - J English
- Department of Gynaecology, Haaglanden Medisch Centrum-Bronovo, Den Haag, the Netherlands
| | - M D Blikkendaal
- Department of Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
| | - A R H Twijnstra
- Department of Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - J Keckstein
- Stiftung Endometrioseforschung (SEF), Westerstede,Germany
- Gynecological Clinic Drs. Keckstein, Villach, Austria
| | - F W Jansen
- Department of Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
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16
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Classification of deep endometriosis (DE) including bowel endometriosis: From r-ASRM to #Enzian-classification. Best Pract Res Clin Obstet Gynaecol 2020; 71:27-37. [PMID: 33558167 DOI: 10.1016/j.bpobgyn.2020.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 12/27/2022]
Abstract
Endometriotic lesions may affect peritoneal and ovarian tissues, cause secondary adhesions, and - in case of deep endometriosis (DE), invade organs such as the urinary bladder, ureters, and bowel. Over decades, several classification systems have been proposed with the rASRM score being the most widely accepted one to date. However, the rASRM classification has certain limitations regarding the description of DE. In contrast, the Enzian classification, which has been updated and modified recently in the form of the so-called #Enzian classification, has proved to be the most suitable tool for staging DE and now also includes peritoneal or ovarian diseases as well as adhesions. In the ideal scenario, a classification for endometriosis can be used with both diagnostic and surgical methods. The present work discusses the pros and cons of scores for endometriosis and highlights the need for using one universal classification system.
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Burla L, Fink D, Imesch P. [Deep Infiltrating Endometriosis - a Systematic Approach to Diagnostics and Surgery Planning]. PRAXIS 2020; 109:725-730. [PMID: 32635852 DOI: 10.1024/1661-8157/a003481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Deep Infiltrating Endometriosis - a Systematic Approach to Diagnostics and Surgery Planning Abstract. Although endometriosis is a common gynaecological clinical picture in women of reproductive age, diagnosis and therapy often begin late after the onset of symptoms. The explanation probably lies on the one hand in the manifold manifestations, the diffuse complaints and the unfortunately rather low awareness of this pathology. On the other hand, the diagnostic procedure itself represents a challenge. In particular, the deeply infiltrating form of endometriosis is a severe form, which often requires surgical therapy. A systematic approach using MRI imaging and preoperative classification using Enzian classification can facilitate the procedure and simplify therapy planning.
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Affiliation(s)
- Laurin Burla
- Klinik für Gynäkologie, Universitätsspital Zürich
| | - Daniel Fink
- Klinik für Gynäkologie, Universitätsspital Zürich
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Keckstein J, Becker CM, Canis M, Feki A, Grimbizis GF, Hummelshoj L, Nisolle M, Roman H, Saridogan E, Tanos V, Tomassetti C, Ulrich UA, Vermeulen N, De Wilde RL. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open 2020; 2020:hoaa002. [PMID: 32064361 PMCID: PMC7013143 DOI: 10.1093/hropen/hoaa002] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 11/27/2019] [Indexed: 12/25/2022] Open
Abstract
STUDY QUESTION How should surgery for endometriosis be performed? SUMMARY ANSWER This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age. WHAT IS KNOWN ALREADY Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe. STUDY DESIGN SIZE DURATION A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis. PARTICIPANTS/MATERIALS SETTING METHODS This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery. MAIN RESULTS AND THE ROLE OF CHANCE The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis. LIMITATIONS REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added. WIDER IMPLICATIONS OF THE FINDINGS These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma. STUDY FUNDING/COMPETING INTERESTS The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose. TRIAL REGISTRATION NUMBER na.
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Affiliation(s)
| | - Joerg Keckstein
- Endometriosis Centre Dres. Keckstein, Richard-Wagner Strasse 18, 9500 Villach, Austria
| | - Christian M Becker
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital Womens Centre, OX3 9DU Oxford, UK
| | - Michel Canis
- Department of Gynaecological Surgery, University Clermont Auvergne CHU, Estaing 1 Place Lucie Aubrac, 63000 Clermont-Ferrand, France
| | - Anis Feki
- Department of Obstetrics and Gynecology, HFR Fribourg Hopital cantonal, 1708 Fribourg, Switzerland
| | - Grigoris F Grimbizis
- 1st Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Tsimiski 51 Street, 54623 Thessaloniki, Greece
| | | | - Michelle Nisolle
- Hôpital de la Citadelle, Department of Obstetrics & Gynecology, 4000 Liège, Belgium
| | - Horace Roman
- Endometriosis Centre, Clinic Tivoli-Ducos, Bordeaux, France
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Ertan Saridogan
- Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing Institute for Women’s Health, University College Hospital, NW1 2BU London, UK
| | - Vasilios Tanos
- Department of Obstetrics and Gynecology, Aretaeio Hospital, 2024 Nicosia, Cyprus
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, 3000 Leuven, Belgium
| | - Uwe A Ulrich
- Department of Obstetrics and Gynaecology, Martin Luther Hospital, 14193 Berlin, Germany
| | | | - Rudy Leon De Wilde
- University Hospital for Gynecology, Carl von Ossietzky Universitat Oldenburg, 26129 Oldenburg, Germany
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The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis. Arch Gynecol Obstet 2019; 300:109-116. [DOI: 10.1007/s00404-019-05157-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/06/2019] [Indexed: 01/26/2023]
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[Endometriosis: Assessment of the Ultrasound-Based Endometriosis Staging System score (UBESS) in predicting surgical difficulty]. ACTA ACUST UNITED AC 2019; 47:265-272. [PMID: 30691974 DOI: 10.1016/j.gofs.2018.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Surgical management of endometriosis may require different levels of surgical skill which influences the orientation of the patient. The Ultrasound-Based Endometriosis Staging System (UBESS) is a score developed in 2016 to predict the difficulty of surgery. To study the correlation between UBESS score and two main surgical classifications in the literature. METHODS Study performed at the center of Poissy, France, between July 2016 and December 2017. Patients who underwent prospective UBESS staging then operated of their endometriosis were included. The patients were classified according to the levels of surgical difficulty of the Royal College of Obstetricians and Gynecologists (RCOG) and the classification created by Chi et al. The criterion of judgment was the correlation between the UBESS stages and RCOG and CHI levels. In a second analysis, we determined the predictive value of the operative plan for items included in the systematic sonographic evaluation described by Menakaya et al. RESULTS: Thirty-three patients were included in the study. Correlation was found to be low between UBESS and RCOG (θ=0.22) and between UBESS and CHI (θ=0.30). The prediction of the operative plan was good for endometrioma, sites specific tenderness, sliding sign, vaginal and digestive tract involvement; but modest for the anterior compartment and uterosacrals ligaments. CONCLUSION In our study on a small number of patients, the UBESS score does not adequately predict the surgical difficulty. Taken separately, the items of systematic sonographic evaluation based on 5 domains successfully predict the operative plan.
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Klemmt PA, Starzinski-Powitz A. Molecular and Cellular Pathogenesis of Endometriosis. CURRENT WOMEN'S HEALTH REVIEWS 2018; 14:106-116. [PMID: 29861704 PMCID: PMC5925869 DOI: 10.2174/1573404813666170306163448] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 02/06/2017] [Accepted: 02/15/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND A substantial body of studies supports the view that molecular and cellular features of endometriotic lesions differ from those of eutopic endometrium. Apart from that, evidence exists that the eutopic endometrium from pa-tients with endometriosis differs from that of females without endometriosis. OBJECTIVE Aberrant expression profiles include a number of non-steroid signaling pathways that exert their putative influ-ence on the pathogenesis of endometriosis at least in part via crosstalk(s) with estrogen-mediated mechanisms. A rational to focus research on non-steroid signal pathways is that they might be remunerative targets for the development and selection of novel therapeutics to treat endometriosis possibly without affecting estrogen levels. RESULTS AND CONCLUSION In this article, we describe molecular and cellular features of endometriotic lesions and focus on the canonical WNT/β-signaling pathway, a key regulatory system in biology (including stem cell homeostasis) and often in pathophysiological conditions such as endometriosis. Recently emerged novel biological concepts in signal transduction and gene regulation like exosomes and microRNAs are discussed in their putative role in the pathogenesis of endometriosis.
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Affiliation(s)
- Petra A.B. Klemmt
- Department of Molecular Cell Biology and Human Genetics, Institute of Cell Biology and Neuroscience, Johann Wolfgang Goethe University of Frankfurt, Max-von-Laue-Str. 13, D-60438Frankfurt am Main, Germany
| | - Anna Starzinski-Powitz
- Department of Molecular Cell Biology and Human Genetics, Institute of Cell Biology and Neuroscience, Johann Wolfgang Goethe University of Frankfurt, Max-von-Laue-Str. 13, D-60438Frankfurt am Main, Germany
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Bazot M, Daraï E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril 2017; 108:886-894. [DOI: 10.1016/j.fertnstert.2017.10.026] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 12/16/2022]
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Bhatti M, Ketheeswaran A, Arnold A, Nesbitt-Hawes E, Deans R, Won H, Abbott J. Pelvic examination may be meaningfully taught to novices and be used to predict operating times for laparoscopic excision of endometriosis in one surgical procedure. Aust N Z J Obstet Gynaecol 2017; 58:239-246. [PMID: 29168563 DOI: 10.1111/ajo.12733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/26/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate whether pelvic examination may be meaningfully taught to novice medical students and its accuracy in predicting operating times for laparoscopic excision of endometriosis at a single surgical procedure. METHODS Women with suspected endometriosis scheduled for laparoscopy underwent pelvic examination to estimate operative time by medical students (novices), trainees, senior clinicians with <10 years surgical experience (experts) and ≥10 years (masters). Examination and intraoperative findings were compared and stage of disease recorded. RESULTS There were 138 estimations of operating time at the initial assessment and 251 estimations of operating time prior to surgery. The median surgical duration was 44 min (range 12-398) and increased progressively with revised American Society for Reproductive Medicine disease stage. Clinical predictions exceeded actual operating times by a median of 18 min (range overestimating by 180 min and underestimating by 120 min) with 80% of procedures completed in less time than predicted and none requiring a second procedure. There was no statistical difference in operative time estimations between the groups with students and trainees underestimating surgical duration by a median of two and five minutes, respectively, experts having a median time difference of zero minutes, and masters overestimating by 4.5 min. CONCLUSION Targeted pelvic examining may be taught to novices (medical students) and can be used to predict operating time at one surgical procedure. Less experienced examiners have a tendency to underestimate surgical duration, with masters overestimating surgical time when scheduling laparoscopies for endometriosis, and increasing disease stage is associated with a less precise estimation of surgical duration.
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Affiliation(s)
- Mominah Bhatti
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | | | - Amy Arnold
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Erin Nesbitt-Hawes
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Rebecca Deans
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - HaRyun Won
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Jason Abbott
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
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Di Paola V, Manfredi R, Castelli F, Negrelli R, Mehrabi S, Pozzi Mucelli R. Detection and localization of deep endometriosis by means of MRI and correlation with the ENZIAN score. Eur J Radiol 2015; 84:568-74. [DOI: 10.1016/j.ejrad.2014.12.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 11/17/2014] [Accepted: 12/14/2014] [Indexed: 12/22/2022]
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Ulrich U, Buchweitz O, Greb R, Keckstein J, von Leffern I, Oppelt P, Renner SP, Sillem M, Stummvoll W, De Wilde RL, Schweppe KW. National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045. Geburtshilfe Frauenheilkd 2014; 74:1104-1118. [PMID: 26157194 PMCID: PMC4470398 DOI: 10.1055/s-0034-1383187] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.
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Affiliation(s)
- U. Ulrich
- Department of Obstetrics and Gynecology, Martin Luther Hospital,
Berlin
| | - O. Buchweitz
- Gynecological Outpatient Surgery Altonaer Straße, Hamburg
| | - R. Greb
- Center for Reproductive Medicine, Dortmund
| | - J. Keckstein
- Department of Obstetrics and Gynecology, Provincial Hospital,
Villach
| | - I. von Leffern
- Department of Obstetrics and Gynecology, Albertinen Hospital,
Hamburg
| | - P. Oppelt
- Department of Obstetrics and Gynecology, Provincial Womenʼs and
Childrenʼs Hospital, Linz
| | - S. P. Renner
- Department of Obstetrics and Gynecology, University of Erlangen School
of Medicine
| | - M. Sillem
- Gynecological Practice and Clinic Rosengarten, Mannheim
| | - W. Stummvoll
- Departement of Gynecology, Hospital of the Sisters of Mercy,
Linz
| | - R.-L. De Wilde
- Department of Obstetrics, Gynecology, and Gynecologic Oncology, Pius
Hospital Oldenburg, University of Oldenburg School of Medicine
| | - K.-W. Schweppe
- Endometriosis Center Ammerland, Ammerland Clinic,
Westerstede
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Ulrich U, Buchweitz O, Greb R, Keckstein J, von Leffern I, Oppelt P, Renner SP, Sillem M, Stummvoll W, Schweppe KW. Interdisciplinary S2k Guidelines for the Diagnosis and Treatment of Endometriosis: Short Version - AWMF Registry No. 015-045, August 2013. Geburtshilfe Frauenheilkd 2013; 73:890-898. [PMID: 24771938 PMCID: PMC3975317 DOI: 10.1055/s-0033-1350810] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- U Ulrich
- Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin
| | | | - R Greb
- Kinderwunschzentrum Dortmund, Dortmund
| | - J Keckstein
- Abteilung für Gynäkologie und Geburtshilfe, Landeskrankenhaus, Villach
| | - I von Leffern
- Klinik für Gynäkologie und Geburtshilfe, Albertinen-Krankenhaus, Hamburg
| | - P Oppelt
- Abteilung für Gynäkologie und Geburtshilfe, Landesfrauen- und Kinderklinik, Linz
| | - S P Renner
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen
| | - M Sillem
- Praxisklinik am Rosengarten, Mannheim
| | - W Stummvoll
- vormals Abteilung für Gynäkologie, Krankenhaus der Barmherzigen Schwestern, Linz
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