Correlation between three-dimensional rectosonography and magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: a preliminary study on the first fifty cases

Ultrasound Diagnosis of Bowel Endometriosis

BACKGROUND

Bowel endometriosis is one of the more severe manifestations of deep endometriosis; it may cause pain and intestinal symptoms. The noninvasive diagnosis of bowel endometriosis is of crucial importance in planning the management of patients affected by this condition.

OBJECTIVES

This review aims to describe how transvaginal ultrasonography (TVS) is performed in patients with suspicion of rectosigmoid endometriosis, the diagnostic performance, and the strengths and limitations of this technique.

METHODS

To identify relevant literature, a literature search was performed across the PubMed and Google Scholar databases up to July 2024.

OUTCOME

Numerous meta-analyses have demonstrated that TVS has high diagnostic accuracy in diagnosing rectosigmoid endometriosis. Rectosigmoid nodules can present with different morphological characteristics, but they are typically described as irregular, hypoechoic nodules located in the anterior wall of the rectosigmoid colon. The presence of "soft markers," such as a negative sliding sign and kissing ovaries, can further reinforce the diagnosis of this condition. Posterolateral parametrial involvement often coexists with large rectal nodules. Introducing water contrast into the rectosigmoid does not improve the performance of TVS in diagnosing rectosigmoid endometriosis.

CONCLUSIONS AND OUTLOOK

TVS should be the first-line investigation in women suspected of having rectosigmoid endometriosis. The widespread use of TVS for the diagnosis of intestinal endometriosis can reduce diagnostic delays and facilitate the treatment of patients affected by this condition.

Postoperative Imaging of Endometriosis

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

Learning Curve for the Detection of Deep Infiltrating Endometriosis and Adenomyosis with 3-D Transvaginal Water Contrast Sonography

Three-dimensional rectosonography (RSG) is a transvaginal sonography technique using rectal water contrast and 3-D acquisitions. The main points of interest of 3-D RSG could be its easy accessibility and its quick learning curve, especially with respect to rectosigmoid lesions. The objective of this prospective observational study was to assess the learning curve of 3-D RSG for the diagnosis of rectosigmoid lesions and for various other locations of deep endometriosis (DE), endometriomas and adenomyosis. From April 2017 to November 2017, 116 patients with suspected pelvic endometriosis were referred to the Croix-Rousse University Hospital, and those who underwent 3-D RSG were included in our study. After a short training period, four residents were asked to perform 3-D RSG by themselves. Each procedure was systematically controlled immediately afterward by a single expert sonographer. The success of the procedure involved the correct identification of various locations of endometriosis (rectosigmoid, uterosacral ligament, retrocervical space, vagina, bladder and ovaries) and adenomyosis, using the expert sonographer's examination as the reference technique. The learning curve was generated using these data and assessed using the Learning Curve Cumulative Summation Test (LC-CUSUM) method. The pooled LC-CUSUM revealed that the required level of achievement was reached after 24 3-D RSGs were performed for the diagnosis of rectosigmoid lesions. All four residents were significantly competent in diagnosing rectosigmoid lesions at the end of their training period, with an α risk <0.05 (T1, p = 0.03; T2, p = 0.0002; T3, p = 0.05; T4, p = 0.02). The LC-CUSUM analysis confirmed that competency was achieved for vaginal DE, torus uterinum DE, US DE, bladder DE, endometriomas and adenomyosis within 17, 27, 38, 19, 17 and 33 scans, respectively. This study provides evidence that the skills required to diagnose endometriosis lesions and adenomyosis with 3-D RSG can be acquired after a brief learning period in an expert center.

Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

MRI for the diagnosis and staging of deeply infiltrating endometriosis: a national survey of BSGE accredited endometriosis centres and review of the literature

OBJECTIVES

Our objective was to establish the primary mode of imaging and MR protocols utilised in the preoperative staging of deeply infiltrating endometriosis in centres accredited by the British Society of Gynaecological Endoscopy (BSGE).

METHODS

The lead consultant radiologist in each centre was invited to complete an online survey detailing their protocols.

RESULTS

Out of 49 centres, 32 (65%) responded to the survey. Two centres performed transvaginal ultrasound as the primary method for preoperative staging of deeply infiltrating endometriosis and the remainder performed MRI. 21/25 centres did not recommend a period of fasting prior to MRI and 22/25 administered hyoscine butylbromide. None of the centres routinely offered bowel preparation or recommended a specific pre-procedure diet. 21/25 centres did not time imaging according to the woman's menstrual cycle, and instructions regarding bladder filling were varied. Rectal and vaginal opacification methods were infrequently utilised. All centres preferentially performed MRI in the supine position - six used an abdominal strap and four could facilitate prone imaging. Just under half of centres used pelvic-phased array coils and three centres used gadolinium contrast agents routinely. All centres performed T1W with fat-suppression and T2W without fat-suppression sequences. There was significant variation relating to other MR sequences depending on the unit.

CONCLUSIONS

There was significant inconsistency between centres in terms of MR protocols, patient preparation and the sequences performed. Many practices were out of line with current published evidence.

ADVANCES IN KNOWLEDGE

Our survey demonstrates a need for evidence-based standardisation of imaging in BSGE accredited endometriosis centres.

Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the Society of Abdominal Radiology endometriosis disease-focused panel

Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.

Diagnostic Performances of Tridimensional Rectosonography and Magnetic Resonance Imaging in Rectosigmoid Endometriosis: A Prospective Cohort Study on 101 Patients

Tridimensional rectosonography (3-D RSG) is a transvaginal ultrasonography procedure combining intrarectal contrast with tridimensional technology. The objectives of this study were to assess the diagnostic performances of 3-D RSG in deep infiltrating rectosigmoid endometriosis using surgery and pathology as the gold standard, and to compare its results with those of magnetic resonance imaging (MRI). Patients referred for endometriosis with symptoms suggesting deep infiltrating intestinal endometriosis (DIE) were included if they agreed to undergo a 3-D RSG and MRI and if there was a surgical indication related to endometriosis. The study was a non-randomized monocentric prospective cohort study (Canadian task force classification Level II-2). From May 2012 to May 2017, 101 patients were included. Sixty patients (59.4%) had bowel involvement of the rectum (n = 21, 20.8%) or of the sigmoid (n = 39, 38.6%) confirmed in surgery and/or in pathologic testing. In the diagnosis of rectosigmoid DIE, 3-D RSG sensitivity, specificity, positive predictive value, negative predictive value, accuracy and κ index were 93%, 95%, 97%, 91%, 94% and 0.88, respectively. For MRI they were 87%, 90%, 93%, 82%, 88% and 0.76, respectively. The accuracy was not significantly different between 3-D RSG and MRI (p = 0.181). In conclusion, 3-D RSG is an effective technique to diagnose rectosigmoid endometriosis and seems to have similar diagnostic performances to MRI for this indication.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Virtual cystoscopy and colonoscopy to assess deep infiltrating endometriosis

Introduction:

Faced with a suspicion of endometriosis, transvaginal sonography is the first-line procedure to diagnose deep infiltrating endometriosis.

Methods:

We recently introduced the FlyThru® mode from TOSHIBA aplio 500. With the 3D acquisition (Multiplanar Reconstruction), we can assess the deep invasion of the endometriosis nodule into the digestive and bladder wall and provide a virtual colonoscopy or cystoscopy. The entire wall of the organ can be explored either by starting the animation or by rotating the arrow. The detection threshold can be adjusted manually from 45 to 100 in order to remove any artifacts.

Results:

We reported two deep infiltrating endometriosis nodules explored with FlyThru mode: the first one in the rectum and the second in the bladder. Similar to a colonoscopy, the virtual animation of the FlyThru mode showed the progression into the intestine lumen until the visualization of the bulge of the nodule. Operators can appreciate precisely the location, the degree of stenosis, and the circumferential involvement of the bowel wall. The bulges of the two nodules were also visible into the bladder. The size of the lesions was assessed and related to bladder volume, which represents important preoperative data.

Conclusion:

Three dimensional-transvaginal sonography combined with the FlyThru mode allows the enhanced practitioner to diagnose and assess the invasion of an endometriosis nodule in a single procedure.

Imaging techniques in endometriosis

Endometriosis is a common gynecological condition affecting up to 15% of the general female population. Here, we present a systematic review of imaging techniques of endometriosis. The aim of this review is to determine the most accurate site-specific preoperative diagnostic tools in order to map, locate, evaluate the extension, and stage the disease. There are important reasons to stage endometriosis: to create a common language, to enable specificity of diagnosis, standardize comparisons, and to facilitate research applications. The requirements of an ideal endometriosis classification system are that it be empirically and scientifically based, be of general consensus, have unambiguous definition of terms, be comprehensive in all cases, have a simple translation from anatomic features to verbal description, reflect disease, predict fertility, predict pain relief, be useful to guide treatment, indicate risk of recurrence, identify clinical situations in which it does not apply, be simple to calculate, and be easy to communicate to women. An extensive search of papers regarding imaging techniques in endometriosis was performed in Pubmed from January 1992 to February 2018, including original peer-reviewed papers, reviews, and international guidelines.

Deep Infiltrating Endometriosis: Comparison Between 2-Dimensional Ultrasonography (US), 3-Dimensional US, and Magnetic Resonance Imaging

OBJECTIVES

To evaluate the diagnostic accuracy of 2-dimensional (2D) and 3-dimensional (3D) transvaginal ultrasonography (US) in comparison with magnetic resonance imaging (MRI) for identification of deep infiltrating endometriosis.

METHODS

In this prospective observational study, 159 premenopausal women who underwent surgery for a clinical suspicion of deep infiltrating endometriosis were prospectively enrolled. All women underwent 2DUS, 3DUS, and MRI. The following 3 locations of deep endometriosis were considered: (1) intestinal; (2) other posterior lesions (retrocervical septum, rectovaginal septum, uterosacral ligaments, and vaginal fornix); and (3) anterior. The sensitivity, specificity, positive predictive value, and negative predictive value of 2D and 3D transvaginal US in comparison with MRI were determined.

RESULTS

Intestinal deep infiltrating endometriosis was identified by 2DUS in 56 of 66 patients, by 3DUS in 59 of 66, and by MRI in 61 of 66. A receiver operating characteristic curve analysis showed optimal results for 2DUS, 3DUS, and MRI (areas under the curve, 0.86, 0.915, and 0.935, respectively) with a statistically significant difference between 2DUS and MRI (P = .0103), even when the 95% confidence interval showed an overlap. Other posterior deep infiltrating endometriosis was identified by 2DUS in 55 of 75 patients, by 3DUS in 65 of 75, and by MRI in 66 of 75. A receiver operating characteristic curve analysis showed very good results for 2DUS, 3DUS, and MRI (areas under the curve, 0.801, 0.838, and 0.857) with no statistically significant differences. In the 12 women with deep infiltrating endometriosis in the anterior location, the nodules were correctly identified by 2DUS in 3 of 12 patients, by 3DUS in 5 of 12, and by MRI in 6 of 12.

CONCLUSIONS

Our results seem to suggest that there is a statistically significant difference between 2DUS and MRI for the intestinal location of deep infiltrating endometriosis, whereas no differences were found among the techniques for the other locations.

Does Computed Tomography-Based Virtual Colonoscopy Improve the Accuracy of Preoperative Assessment Based on Magnetic Resonance Imaging in Women Managed for Colorectal Endometriosis?

STUDY OBJECTIVE

To evaluate whether combining computed tomography-based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis.

DESIGN

Retrospective study using prospectively recorded data (Canadian Task Force classification II-2).

SETTING

University tertiary referral center.

PATIENTS

Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016.

INTERVENTIONS

Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used.

MEASUREMENTS AND MAIN RESULTS

Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned.

CONCLUSION

Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

Rectal water contrast transvaginal ultrasound versus double-contrast barium enema in the diagnosis of bowel endometriosis

OBJECTIVES

The aim of study was to compare the accuracy between rectal water contrast transvaginal ultrasound (RWC-TVS) and double-contrast barium enema (DCBE) in evaluating the bowel endometriosis presence as well as its extent.

DESIGN AND SETTING

198 patients at reproductive age with suspicious bowel endometriosis were included. Physicians in two groups specialised at endometriosis performed RWC-TVS as well as DCBE before laparoscopy and both groups were blinded to other groups' results. Findings from RWC-TVS or DCBE were compared with histological results. The severity of experienced pain severity through RWC-TVS or DCBE was assessed by an analogue scale of 10 cm.

RESULTS

In total, 110 in 198 women were confirmed to have endometriosis nodules in the bowel by laparoscopy as well as histopathology. For bowel endometriosis diagnosis, DCBE and RWC-TVS demonstrated sensitivities of 96.4% and 88.2%, specificities of 100% and 97.3%, positive prediction values of 100% and 98.0%, negative prediction values of 98.0% and 88.0%, accuracies of 98.0% and 92.4%, respectively. DCBE was related to more tolerance than RWC-TVS.

CONCLUSIONS

RWC-TVS and DCBE demonstrated similar accuracies in the bowel endometriosis diagnosis; however, patients showed more tolerance for RWC-TVS than those with DCBE.

Magnetic resonance enema vs rectal water-contrast transvaginal sonography in diagnosis of rectosigmoid endometriosis

OBJECTIVE

To compare the accuracy of magnetic resonance enema (MR-e) and rectal water-contrast transvaginal sonography (RWC-TVS) in the diagnosis of rectosigmoid endometriosis.

METHODS

This prospective study included 286 patients of reproductive age with clinical suspicion of rectosigmoid endometriosis. Patients underwent MR-e and RWC-TVS before laparoscopic excision of endometriotic lesions. The findings of MR-e and RWC-TVS were compared with surgical and histological results.

RESULTS

Of the 286 patients included in the study, 151 (52.8%) had rectosigmoid endometriosis. MR-e and RWC-TVS had similar accuracy in the diagnosis of rectosigmoid endometriosis (P = 0.063). In the diagnosis of rectosigmoid endometriosis with MR-e, the sensitivity was 95.4% (95% CI, 90.7-99.1%), specificity was 97.8% (95% CI, 93.6-99.5%), positive predictive value (PPV) was 98.0% (95% CI, 94.1-99.6%), negative predictive value (NPV) was 95.0% (95% CI, 89.9-97.9%), positive likelihood ratio (LR+) was 42.91 (95% CI, 14.01-131.46) and negative likelihood ratio (LR-) was 0.05 (95% CI, 0.02-0.10). For diagnosis with RWC-TVS, sensitivity was 92.7% (95% CI, 87.3-96.3%), specificity was 97.0% (95% CI, 92.6-99.2%), PPV was 97.2% (95% CI, 93.0-99.2%), NPV was 92.3% (95% CI, 86.6-96.1%), LR+ was 31.29 (95% CI, 11.90-82.25) and LR- was 0.08 (95% CI, 0.04-0.13). MR-e and RWC-TVS underestimated the size of the endometriotic nodules; for both imaging techniques the underestimation was greater for nodules with a diameter ≥ 30 mm. There was no significant difference in the mean intensity of pain experienced by the patients during the two examinations.

CONCLUSIONS

RWC-TVS should be the first-line investigation in patients with clinical suspicion of rectosigmoid endometriosis and physicians should be trained in performing this examination. Considering that MR-e is more expensive than RWC-TVS, it should be used only when the findings of RWC-TVS are unclear. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

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

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

[Pictures balance for optimal surgical management of pelvic endometriosis. Imaging and surgery of endometriosis]

Endometriosis is a frequent benign pathology that is found in 10-15% of women and in 20% of infertile women. It has an impact on fertility, but also in everyday life. If medical treatment fails, surgical treatment can be offered to the patient. To provide adequate treatment and give clearer information to patients, it seems essential to achieve an optimal preoperative imaging assessment. Thus, the aim of this work is to define the information expected by the surgeon and the indications of each imaging test for each compartment of the pelvis, allowing an ideal surgical management of pelvic endometriosis. We will not discuss imaging techniques' principles and we will not develop the indications and surgical techniques.

Computed tomography-based virtual colonoscopy in the assessment of bowel endometriosis: The surgeon's point of view

OBJECTIVE

To discuss the role of computed tomography-based virtual colonoscopy (CTC) in preoperative assessment of bowel endometriosis.

METHODS

Retrospective study using data prospectively recorded, including 127 patients with colorectal endometriosis, having undergone CTC for bowel endometriosis. The study was conducted in a tertiary referral center during 38 consecutive months. Preoperative assessment included CTC, magnetic resonance imaging (MRI), endorectal ultrasound (ERUS) and clinical examination. Information concerning identification of deep infiltrating endometriosis (DIE) of the bowel, the length and height of colorectal involvement, stenosis of digestive lumen and associated digestive localizations were compared with intraoperative findings.

RESULTS

Sensitivity and specificity of CTC for DIE of the rectum, the sigmoid colon, associated digestive localizations, and stenosis of the digestive lumen were respectively 97% and 84%, 93% and 88%, 84% and 97%, 96% and 96%. Intraoperative estimation of the length of digestive tract involved by DIE was closer to that provided by CTC than those provided by MRI and ERUS. When CTC revealed stenosis of digestive lumen, higher rates of colorectal resection (63% vs. 9.6%, < 0.001) and disc excision (25.9% vs. 11%, 0.03) were recorded.

DISCUSSION

For those surgeons using various procedures for management of bowel endometriosis, accurate information on the length and height of bowel involvement, as well as the existence of bowel stenosis enables informed decision regarding the feasibility of conservative techniques versus bowel resection. Preoperative identification of associated localizations above the sigmoid colon is another major advantage related to CTC.

CONCLUSIONS

CTC provides accurate data on the length and height of colorectal involvement by DIE, stenosis of digestive lumen and associated lesions of digestive tract, which impact on the choice of surgical procedure.