Sonography and MR imaging for the assessment of deep pelvic endometriosis

Frequency of cul-de-sac obliteration in surgery for pelvic organ prolapse: a retrospective analysis

INTRODUCTION AND HYPOTHESIS

We aimed to clarify the frequency of cul-de-sac obliteration in patients undergoing POP surgery.

METHODS

We retrospectively reviewed patients who underwent laparoscopic POP surgery at our hospital between April 2017 and September 2021.

RESULTS

In total, 191 cases were included in the analysis. Ten patients (5.2%) had cul-de-sac obliteration. No difference in age (73 years vs. 72 years, P = 0.99), parity (2 vs. 2, P = 0.64), or body mass index (BMI) (25.7 kg/m2 vs. 24.7 kg/m2, P = 0.34) was observed between the cul-de-sac obliteration and normal groups. No significant differences were observed in the rate of previous abdominal surgery (50.0% vs. 32.6%, P = 0.46), rate of POP - quantification system (POP-Q) ≥ 2 posterior prolapse (40.0% vs. 46.4%, P = 0.98), and effect of defecation symptoms on the prolapse quality of life (p-QOL) score (vaginal bulge emptying bowels: 2.5 vs. 3.5, P = 0.15; empty bowel feeling: 3 vs. 3, P = 0.72, constipation: 3.5 vs. 3, P = 0.58; straining to open bowels: 3.5 vs. 3, P = 0.82; empty bowels with fingers: 1 vs. 1, P = 0.55) between the cul-de-sac obliteration and normal groups. Multivariate analysis of risk factors for the cul-de-sac obliteration was performed for age, number of births, previous abdominal surgery, and presence of rectocele; however no significant risk factors were extracted.

CONCLUSION

Predicting cul-de-sac obliteration preoperatively in patients undergoing POP surgery based on age, number of previous surgeries, previous abdominal surgeries, rectocele, and defecation symptoms is difficult.

Superficial Endometriosis at Ultrasound Examination-A Diagnostic Criteria Proposal

The actual prevalence of superficial endometriosis is not known. However, it is considered the most common subtype of endometriosis. The diagnosis of superficial endometriosis remains difficult. In fact, little is known about the ultrasound features of superficial endometriotic lesions. In this study, we aimed to describe the appearance of superficial endometriosis lesions at ultrasound examination, with laparoscopic and/or histologic correlation. This is a prospective study on a series of 52 women with clinical suspicion of pelvic endometriosis who underwent preoperative transvaginal ultrasound and received a confirmed diagnosis of superficial endometriosis via laparoscopy. Women with ultrasound or laparoscopic findings of deep endometriosis were not included. We observed that superficial endometriotic lesions may appear as a solitary lesions, multiple separate lesions, and cluster lesions. The lesions may exhibit the presence of hypoechogenic associated tissue, hyperechoic foci, and/or velamentous (filmy) adhesions. The lesion may be convex, protruding from the peritoneal surface, or it may appear as a concave defect in the peritoneum. Most lesions exhibited several features. We conclude that transvaginal ultrasound may be useful for diagnosing superficial endometriosis, as these lesions may exhibit different ultrasound features.

Role of preoperative ultrasound mapping in the surgical management of deep infiltrating endometriosis: a prospective observational study

Background

Endometriosis is a challenging gynecological condition that has a profound influence on the quality of life of affected women. Transvaginal ultrasound is considered the first-line imaging method in preoperative assessment of the extent and severity of endometriosis. Accurate preoperative mapping can aid the surgeon in patient counselling, selection of the most appropriate surgical method that minimizes the operative and post-operative complications. The aim of our study is to evaluate the accuracy of transvaginal sonography (TVS) in precisely assessing the size, location and extent of deep infiltrating endometriosis (DIE) using a new modified endometriosis mapping proforma with histopathological confirmation. Our prospective observational study included 101 women with clinically suspected DIE who underwent TVS followed by laparoscopy from October 2018 to December 2020 with a maximum of 4 weeks interval. Precise mapping of DIE was done during TVS and laparoscopy. Results were correlated with histopathology findings.

Results

DIE was confirmed by histopathology in 88 patients. Sensitivity and specificity for individual DIE locations were rectovaginal septum 67.9% and 98.6%; vagina 52.2% and 98.7%; uterosacral ligaments 82.5% and 96.2%; torus 96.4% and 97.3%; parametrium 68.8% and 96.9%; rectum 100% and 98.8%; bladder 100% and 100%, ureters 63.4% and 99.0%; scar endometriosis 100% and 100%; pouch of Douglas obliteration 97.7% and 100%. No statistically significant difference was detected between ultrasound and histopathology size. Ultrasound tended to underestimate the lesion size; the underestimation was more pronounced for lesions > 3 cm. “Butterfly” and “tram-track” signs are two new sonographic signs related to posterior compartment DIE. No post-operative complications were recorded. There were no cases of DIE recurrence. Eleven out of 22 cases of infertility achieved pregnancy during 18 months follow-up.

Conclusion

TVS provides a thorough and accurate evaluation of the extent of endometriosis. An experienced radiologist can use E-PEP to provide an accurate demonstration of the location and extent of DIE which helps the surgeon select the most appropriate surgical approach ensuring radical treatment of the disease and minimizing short- and long-term complications.

Transvaginal Ultrasound as a First-Line Approach in Deep Endometriosis: A Pictorial Essay

Endometriosis (EMS) is a benign condition characterized by a systemic inflammation that affects fertile women at reproductive age. Ultrasound became, in recent years, the method of choice for both effective diagnostic and preoperative planning. Therefore, accurate characterization and mapping of endometriotic lesions is imperative in such circumstances to enable optimal approach of treatment, whether surgical or non-surgical based on the severity of the findings. This pictorial essay outlines a practical approach to evaluating patients with deep endometriosis by means of transvaginal ultrasound. The technical aspects are in conjunction with both consensus of the International Deep Endometriosis Analysis (IDEA) group and the hands-on experience acquired through daily clinical practice.

Imaging of non-traumatic urinary bladder emergencies

Non-traumatic urinary bladder emergencies are rare but critical diagnoses to make in an emergency setting. Acute urinary bladder pathologies require an accurate and timely diagnosis to ensure a favorable clinical outcome. Multidetector computed tomography (CT) is the imaging modality of choice for acute and emergent conditions affecting the urinary bladder. MRI is helpful as a problem-solving modality due to better soft tissue characterization and higher in-plane resolution. The purpose of this article is to illustrate the spectrum of urinary bladder emergencies, review the imaging findings, and briefly describe the role of imaging in the evaluation of such patients. Although there are a few cases of bladder emergencies been reported separately, the literature summarizing the spectrum is lacking. The objective of this article is to review the imaging of acute emergencies involving urinary bladder that will help us to think beyond non-specific conclusion in an emergency setting. For the sake of focused discussion, traumatic bladder emergencies will be excluded in this review. In the era of highly image reliant clinical practice, radiologists must be familiar with the diagnostic strategy to approach these entities.

New biomarkers in endometriosis

Endometriosis is a benign gynecological disorder which presents significant challenges in terms of diagnosis and management. Despite decades of research, there are no sufficiently sensitive and specific signs and symptoms nor blood tests for the clinical confirmation of endometriosis, which hampers prompt diagnosis and treatment. The huge majority of potential biomarkers has been discarded in research stage and very few have been translated to clinical practice. Serum CA-125 is the most studied and used one, but studies have shown its poor diagnostic performance. Several factors involved in the chronic inflammatory process of endometriosis, such as hormones, cytokines, chemokines, angiogenic factors, oxidative stress markers and others, have been implicated in the disease's pathogenesis and have been extensively studied, but not a single one has successfully been able to accurately identify the disease. MicroRNAs have emerged more recently but their utility to detect endometriosis remains uncertain. The search for a biomarker or a set of biomarkers is still open and may benefit from novel molecular biology and bioinformatics approaches to mine and uncover molecular signatures specifically associated with the disease.

MRI-Ultrasound Fusion Imaging for Diagnosis of Deep Infiltrating Endometriosis - A Critical Appraisal

Purpose

It was the aim of our study to evaluate this procedure using pelvic anatomical landmarks in order to assess the accuracy of fusion imaging and to critically evaluate the applicability in daily practice.

Methods

In a prospective, single center study, 10 patients with clinical signs of deep infiltrating endometriosis (DIE) were selected. We measured the distance between the landmark organ and the target shown by the software system (measurement 1). Measurement 2 depicts the distance between the landmark and the nearest calibration point. The calibration inaccuracy was measured as a third type of measurement (measurement 3).

Results

Measurement 1: the average distance between the organ landmark to the target was 13.6 mm (range: 0–96 mm). Measurement 2: in 31 of the 40 attempts (77.5 %), we could measure the distance from the landmark organ to the nearest calibration point. The average distance was 34.4 mm (range: 0–69 mm).

Measurement 3: A perfect match was seen in 6 of 20 attempts (30.0 %). There was a deviation in 14 of the 20 attempts (70.0 %). The mean distance was 11.1 mm (range: 6–23 mm). Conclusion Although very promising, MRI-ultrasound fusion imaging (MUFI) currently cannot be readily implemented into daily practice as a routine evaluation of DIE.

Poor sensitivity of transvaginal ultrasound markers in diagnosis of superficial endometriosis of the uterosacral ligaments

Introduction:

This study aims to evaluate the use of transvaginal ultrasound in predicting superficial endometriosis near the uterosacral ligaments, in women with symptoms of endometriosis.

Methods:

This was a prospective observational pilot study in which women with symptoms of endometriosis underwent detailed pre-operative transvaginal ultrasound to assess the uterosacral ligament area for thickening (‘white line sign’), tenderness and small hypoechoic nodules. Women with deep infiltrating endometriosis were excluded. The test characteristics of transvaginal ultrasound were reported using histologically or visually proven endometriosis near the ipsilateral uterosacral ligament as a reference standard.

Results:

In 81 patients who underwent pre-operative transvaginal ultrasound and laparoscopy, no marker had appropriate test characteristics for a diagnostic or screening test for endometriosis near the ipsilateral uterosacral ligament when used alone. The presence of a small hypoechoic nodule on the white line had the highest specificity of the three markers, at 82% (95% confidence interval 66%–92%). Quantitative measurement of the white line also achieved a high specificity of ≥96% using a cut-off of 5.8 and 6.1 mm, on the left and right sides, respectively.

Conclusion:

Transvaginal ultrasound of the uterosacral ligament area using the three proposed markers is not a clinically useful screening test for superficial endometriosis near the uterosacral ligaments. A grossly thickened white line (≥5.8 mm) and/or the presence of small hypoechoic nodules are highly specific findings for superficial endometriosis near the uterosacral ligaments and may prompt surgical management.

Is training sufficient for ultrasound operators to diagnose deep infiltrating endometriosis and bowel involvement by transvaginal ultrasound?

OBJECTIVES

To assess and compare the diagnostic accuracy of transvaginal ultrasonography (TVUS) by trained or untrained ultrasound operators in deep infiltrating endometriosis (DIE) imaging, for diagnosing DIE and bowel involvement.

METHODS

This was an observational study of patients with clinically suspected DIE operated in a reference center. TVUS was performed pre-operatively by a trained or/and untrained ultrasound operator to search for DIE and rectal involvement. During surgery, DIE was diagnosed according to macroscopic and histological criteria. Sensitivity (Se), specificity (Sp) and c-index were calculated with 95% confidence intervals for trained and untrained operators, if TVUS results were significantly predictive of DIE and rectal involvement at p<0.05.

RESULTS

115 patients were included: 100 (87%) had DIE and 34 (29.6%) had bowel involvement. TVUS was performed by a trained ultrasound operator for 70 patients and by an untrained one for 56 patients. When performed by a trained operator, TVUS significantly predicted DIE with a Se of 58% (95% CI, 46-70), a Sp of 87.5% (95% CI, 63-100) and a c-index of 0.73 (95% CI, 0.59-0.87). TVUS performed by an untrained operator was not significantly predictive of DIE (p=0.58). Rectal involvement was significantly predicted by TVUS performed by a trained operator with a Se of 40% (95% CI, 23-59), a Sp of 93% (95% CI, 86-100) and a c-index of 0.67 (95% CI, 0.56-0.77). None of the untrained ultrasound operators diagnosed a bowel involvement.

CONCLUSION

TVUS is not sufficient to diagnose DIE and bowel involvement, in particular when performed by untrained ultrasound operators.

Diagnosis of Bowel Endometriosis: A Review

Since the presence of intestinal endometriosis cannot be reliably established by physical examination or the evaluation of intestinal symptoms, imaging techniques are required for the diagnosis of bowel endometriosis. This review evaluates the techniques available for the diagnosis of intestinal endometriosis based on a search of the Medline database and Embase up to February 2010. Several studies have proved that radiological techniques (double contrast barium enema, magnetic resonance imaging, and multidetector computerized tomography enteroclysis) are able to accurately diagnose intestinal endometriosis. Magnetic resonance imaging has the advantage of determining the presence of deep endometriotic lesions in other pelvic locations. Rectal endoscopic ultrasonography can precisely determine the presence of bowel endometriosis but its use is limited by the availability of the equipment required to carry out the exam. Over the last five years, several studies have proved that transvaginal ultrasonography is accurate in the diagnosis of rectosigmoid endometriosis; in addition, this exam is well tolerated by patients and is inexpensive. Therefore, transvaginal ultrasonography should be the first-line investigation in patients with suspected intestinal endometriosis.

Magnetic Resonance Colonography May Predict the Need for Bowel Resection in Colorectal Endometriosis

Purpose

To define if MRI findings in patients with deep pelvic endometriosis (DPE) may be predictive for the need of bowel resection.

Material and Methods

A retrospective survey of 196 pelvic MRIs of women who received laparoscopic procedures for DPE was carried out. A pelvic MRI was performed in all patients: it consisted in T2w-TSE sequences in axial, sagittal, and coronal planes and T1w and THRIVE sequences in the axial plane; the exam was completed by MR-Colonography. Intestinal lesions were measured in short and long axis and the degree of stenosis was established. A multivariate logistic regression was used to identify the predictors of intestinal resection.

Results

57/196 patients received an intestinal resection. Multivariate logistic regression demonstrated a predictive value of short axis (Odds-Ratio = 2.29, p = 0.011) and stenosis (Odds-Ratio = 1.20, p = 0.003). ROC analysis showed that a cut-off value of 11 mm for the short axis and 30% for the stenosis may correctly classify, respectively, 96,94% (sensitivity 92,9% and specificity 98,56%) and 97,96% (sensitivity 94,74% and specificity 99,3%) of the cases.

Conclusion

The presence of an endometriotic rectal nodule > 11 mm in short axis causing a stenosis > 30% in pelvic MRI reliably predicts the need of a rectal resection.

Transvaginal sonography in the diagnosis of deep infiltrating endometriosis: A review

This review summarizes the current evidence regarding the diagnostic accuracy of sonography (US) in women with deep infiltrating endometriosis (DIE). It is well known that transvaginal ultrasound (TVUS) can detect ovarian endometriomas with a high degree of sensitivity. In recent years, US has also been used to detect DIE. In the hands of an experienced sonologist, the sensitivity and specificity of TVUS in the detection of DIE is comparable to those of MRI. TVUS can eliminate the need for an MRI in the majority of patients and reduce the need for diagnostic laparoscopy, proving to be an important tool in preoperative planning. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:313-318, 2017.

Management of Endometriomas Prior to IVF

Endometriosis causes a decrease in fertility in affected patients. The different forms of the disease, peritoneal, ovarian, deep infiltrating and adenomyosis, are often present in varying degrees in the same patient, either together or individually, and cause infertility through a pathogenesis that is not yet clear. A significant number of women with endometriosis and endometriomas will eventually seek assisted reproductive technology (ART) for conception. The specific impact of endometriomas alone and the impact of surgical intervention for endometriomas on the reproductive outcome of women undergoing in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) are areas that need further clarification and, for this reason, the management of endometriomas before clinical IVF is a very complex topic.

In order to provide useful information for the clinical management of patients with endometriomas having IVF, in this review we investigated: the impact of the presence of endometriomas, both individually and associated with other types of the disease, on IVF techniques; the possible role of surgery and its possible negative effects; the risks and difficulties related to conservative management during IVF procedures.

Magnetic resonance imaging of pelvic endometriosis

Endometriosis is common in women of reproductive age; it can cause pelvic pain and infertility. It is important to diagnose endometriosis and to thoroughly evaluate its extension, especially when surgical treatment is being considered. Magnetic resonance imaging (MRI) with careful examination technique and interpretation enables more accurate and complete diagnosis and staging than ultrasonography, especially in cases of deep pelvic endometriosis. Furthermore, MRI can identify implants in sites that can be difficult to access in endoscopic or laparoscopic explorations. In this article, we describe the appropriate MRI protocol for the study of pelvic endometriosis and the MRI signs of pelvic organ involvement. It is necessary to know the subtle findings and to look for them so we can ensure that they are not overlooked. We describe clinical grading systems for endometriosis and review the diagnostic efficacy of MRI in comparison with other imaging techniques and surgery.

Adenomyosis: what is new?

Adenomyosis is described as the benign invasion of endometrium into the myometrium, with endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium. It may affect 20% of female population and most widely seen among perimenopausal and multiparous women. Its etiopathogenesis, diagnosis, clinical findings and current various treatment options will be discussed in this article.

Location-dependent value of pelvic MRI in the preoperative diagnosis of endometriosis

OBJECTIVES

To investigate the value of magnetic resonance imaging (MRI) in the preoperative diagnosis of specific anatomical locations of endometriosis.

STUDY DESIGN

Between July 2008 and April 2011, 152 women (mean age 33.5 ± 6.1 years) with clinical and sonographic suspicion of endometriosis underwent pelvic MRI using T2 and unenhanced T1 sequences with and without fat saturation. Two radiologists interpreted the following regions by consensus according to a standardized protocol: ovaries, vagina, pouch of Douglas, rectosigmoid colon, uterosacral ligament (USL), bladder, peritoneum, and other pelvic regions. The results of MRI were retrospectively correlated with the laparoscopic and histopathologic findings. The main outcome parameters, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, positive likelihood ratio (LR+) and the negative likelihood ratio (LR-), were determined.

RESULTS

Sensitivity, specificity, PPV, NPV, accuracy, positive and the negative likelihood ratio were 87.6%, 84.6%, 94.3%, 70.2%, 86.8%, 5.69 and 0.15 for the pouch of Douglas (vagina: 81.4%, 81.7%, 79.2%, 83.8%, 81.6%, 4.45, 0.23; rectosigmoid colon: 80.2%, 77.5%, 80.2%, 77.5%, 78.9%, 3.56, 0.25; USL: 77.5%, 68.2%, 77.5%, 68.2%, 73.7%, 2.44, 0.33; ovaries: 86.3%, 73.6%, 78.4%, 82.8%, 80.3%, 3.27, 0.19; urinary bladder: 81.0%, 94.7%, 70.8%, 96.9%, 92.8%, 15.15, 0.20; peritoneum: 35.3%, 88.1%, 60.0%, 73.0%, 70.4%, 2.97, 0.73). All endometriotic implants at other localization were detected (abdominal wall in 4, groin in one patient).

CONCLUSIONS

The value of MRI in preoperative diagnosis of endometriosis is dependent on the location of endometriosis. The highest accuracy was found in bladder endometriosis and the lowest in peritoneal endometriosis.

Accuracy of transvaginal sonography and contrast-enhanced magnetic resonance-colonography for the presurgical staging of deep infiltrating endometriosis

OBJECTIVE

To investigate the accuracy of transvaginal sonography (TVS) and contrast-enhanced magnetic resonance-colonography (CE-MR-C) for the presurgical assessment of deep infiltrating endometriosis (DIE).

METHODS

Ninety women were enrolled prospectively for suspicion of DIE. All patients underwent TVS and CE-MR-C, with each operator blinded to the results of the other exam, before laparoscopy. The sites of DIE examined by both imaging techniques were: rectovaginal septum, pouch of Douglas, uterosacral ligaments, vesicouterine pouch, bowel, bladder and vagina. The presence of adhesions and the involvement of adnexa and of a previous abdominal scar, when there was clinical suspicion, were also evaluated. TVS and CE-MR-C findings were compared with laparoscopic and histological results.

RESULTS

Endometriosis was confirmed by laparoscopy in 95.6% (86/90) of cases. In 82.2% (74/90) of patients there was DIE. The global accuracy for TVS in the detection of DIE was 89.2%, sensitivity was 81.1%, specificity was 94.2%, positive predictive value was 89.6%, negative predictive value was 89.0%, the positive likelihood ratio was 13.9 and the negative likelihood ratio was 0.2. For CE-MR-C, these values were 87.2%, 71.1%, 97.1%, 93.7%, 84.6%, 24.4 and 0.3, respectively. CE-MR-C allowed diagnosis of all cases of bowel involvement; the accuracy for infiltration and stenosis was 100%. The accuracy of TVS for rectosigmoid nodules was 91.1% and that for infiltration was 88.9%.

CONCLUSIONS

Both TVS and CE-MR-C showed satisfactory results for the presurgical assessment of DIE. TVS appears to be a powerful, simple, feasible, cost-effective tool for preoperative staging of DIE. CE-MR-C is an 'X-ray free' technique, which could be reserved for cases with deep infiltrating rectosigmoid lesions and for the prediction of stenosis and involvement of the upper part of the colon and small intestine.

Patients with endometriosis of the rectosigmoid have a higher percentage of natural killer cells in peripheral blood

STUDY OBJECTIVE

To estimate the concentration of natural killer (NK) cells in the peripheral blood in patients with and without endometriosis.

DESIGN

Case-control study (Canadian Task Force classification II-2).

SETTING

Tertiary referral hospital.

PATIENTS

One hundred fifty-five patients who had undergone videolaparoscopy were divided into 2 groups: those with endometriosis (n = 100) and those without endometriosis (n = 55).

INTERVENTIONS

The percentage of NK cells relative to peripheral lymphocytes was quantified at flow cytometry in 155 patients who had undergone laparoscopy. In addition to verifying the presence of endometriosis, stage of disease and the sites affected were also evaluated.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) percentage of NK cells was higher (15.3% [9.8%]) in patients with endometriosis than in the group without the disease (10.6% [5.8%]) (p < .001). The percentage of NK cells was highest (19.8 [10.3%]) in patients with advanced stages of endometriosis and in those in whom the rectosigmoid colon was affected. In a statistical model of probability, the association of this marker (NK cells ≥11%) with the presence of symptoms such as pain and intestinal bleeding during menstruation and the absence of previous pregnancy yielded a 78% likelihood of the rectosigmoid colon being affected.

CONCLUSION

Compared with patients without endometriosis, those with endometriosis demonstrate a higher concentration of peripheral NK cells. The percentage of NK cells is greater, primarily in patients with advanced stages of endometriosis involving the rectosigmoid colon. Therefore, it may serve as a diagnostic marker for this type of severe endometriosis, in particular if considered in conjunction with the symptoms.

Deep pelvic endometriosis: MR imaging

OBJECTIVE

The purpose of the pictorial essay is to show the MR imaging (MRI) findings associated with deep pelvic endometriosis.

CONCLUSION

MRI is an excellent imaging modality for the evaluation of patients with deep pelvic endometriosis, showing high accuracy in the diagnosis and prediction of disease extent. Its multiplanar capabilities and superior soft tissue contrast are extremely useful in the detection of deeply infiltrating endometriotic implants, even in the setting of intense desmoplastic response that may result in complete obliteration of the posterior cul-de-sac and fixed retroversion of the uterus, which limits the scope of laparoscopy. The use of endovaginal and rectal contrast is helpful to better delineate the anatomy of interest and map out the extent of disease, contributing to more effective treatment planning.

Value of transvaginal ultrasound in assessing severity of pelvic endometriosis

OBJECTIVE

The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis.

METHODS

Consecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. The severity of endometriosis was assessed preoperatively using TVS and the findings were compared with the results obtained by laparoscopy using the American Society for Reproductive Medicine (ASRM) classification.

RESULTS

In total, 201 women had preoperative TVS and laparoscopies. Of these, no endometriosis was found at laparoscopy for 62/201 (30.8%; 95% CI, 24.8-37.5), whereas 33/201 (16.4%; 95% CI, 11.9-22.2) had minimal endometriosis, 31/201 (15.4%; 95% CI, 11.1-21.1) had mild endometriosis, 27/201 (13.4%; 95% CI, 9.4-18.8) had moderate endometriosis and 48/201 (23.9%; 95% CI, 18.5-30.2) had severe endometriosis. The sensitivity and specificity of the TVS diagnosis of severe pelvic endometriosis were 0.85 (95% CI, 0.716-0.934) and 0.98 (95% CI, 0.939-0.994), respectively, and the positive and negative likelihood ratios were 43.5 (95% CI, 14.1-134) and 0.15 (95% CI, 0.075-0.295), respectively. Overall, there was a good level of agreement between ultrasound and laparoscopy in identifying absent, minimal, mild, moderate and severe disease (quadratic weighted kappa = 0.786). The mean ASRM score difference between TVS and laparoscopy in assessing severity of endometriosis was -2.398 (95% CI, -4.685 to -0.1112) and the limits of agreement were -34.62 (95% CI, -38.54 to -30.709) to 29.83 (95% CI, 25.91-33.74).

CONCLUSIONS

TVS is a good test for assessing the severity of pelvic endometriosis. TVS is particularly accurate in detecting severe disease, which could facilitate more effective triaging of women for appropriate surgical care.

Laparoscopic conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis

BACKGROUND

this study aims to evaluate the effectiveness and safety of laparoscopic conservative management of ureteral endometriosis.

METHODS

Eighty cases of histologically confirmed endometriosis affecting the ureter, 10 of which with bladder involvement were prospectively studied. In detail, patients were 13 women with ureteral stenosis (7 with hydronephrosis), 32 with circular lesions totally encasing the ureter, and 35 with endometriotic foci on the ureteral wall, but not completely encasing it. They were submitted to laparoscopic ureterolysis with or without partial cystectomy, ureteroneocistostomy. The rate of surgical complications, the recurrence rate, the patients' satisfaction rate was assessed during 22 months (median) follow-up.

RESULTS

Laparoscopic ureterolysis was employed for all patients and set free the ureter from the disease in 95% of cases, whereas ureteroneocystostomy was necessary for 4 patients showing severe stenosis with hydronephrosis, among which 2 had intrinsic endometriosis of the ureteral muscularis. Three post-surgery ureteral fistulae occurred in cases with ureteral involvement longer than 4 cm: two cases were successfully treated placing double J catheter, the third needed ureteroneocistostomy. During follow-up, ureteral endometriosis recurred in 2 patients who consequently underwent ureteroneocystostomy. Most patients expressed high satisfaction rate throughout the whole follow-up period.

CONCLUSION

laparoscopic ureterolysis is effective and well tolerated in most cases of ureteral endometriosis. Ureteroneocystostomy is a better strategy for patients with extended (more than 4 cm) ureteral involvement or with severe stenosis with or without hydronephrosis.

Rectovaginal endometriosis – a frequently missed diagnosis

To assess the proportion of women found to have rectovaginal endometriosis who underwent a previous laparoscopy with negative findings, a 5-year retrospective observational study was carried out at the University Hospital of Wales, Cardiff UK, from 2001 to 2005. A total of 61 cases with potential symptoms of rectovaginal endometriosis who underwent laparoscopy were identified. Rectovaginal endometriosis was identified in 16 of these cases. Previous laparoscopy was carried out in 33 of these 61 cases. In the group of women found to have rectovaginal endometriosis, 14 cases of rectovaginal endometriosis were not identified by pre-referral laparoscopy. This study supports the anecdotal idea that rectovaginal endometriosis is an often missed diagnosis at the time of laparoscopy. Diagnostic laparoscopy by generalist gynaecologists frequently fails to diagnose rectovaginal endometriosis. The routine use of rectal probes at laparoscopy is recommended to increase diagnostic accuracy.

Avaliação da concordância entre a ultrassonografia transvaginal e a ressonância magnética da pelve na endometriose profunda, com ênfase para o comprometimento intestinal

OBJETIVO: Comparar achados ultrassonográficos e de ressonância magnética na endometriose profunda, com ênfase para o comprometimento intestinal. MATERIAIS E MÉTODOS: Dezoito pacientes entre 23 e 49 anos de idade, com suspeita clínica e exame ginecológico sugestivo de endometriose profunda, foram submetidas a ultrassonografia e ressonância magnética para correlação dos achados. RESULTADOS: A ultrassonografia detectou 40 lesões e a ressonância magnética detectou 53 lesões na pelve. O estudo comparativo entre ultrassonografia e ressonância magnética na detecção das lesões não mostrou diferença estatística significativa (p > 0,19 e p > 0,14, respectivamente). Considerando-se a junção retossigmoide, a ressonância magnética detectou uma lesão (5,6%) e a ultrassonografia apontou quatro lesões (22,2%). Nas lesões retais, a ultrassonografia apontou oito lesões (44,4%) e a ressonância magnética, sete lesões (38,9%). CONCLUSÃO: A concordância entre a ressonância magnética e a ultrassonografia não foi boa na junção retossigmoide e no reto, sendo que a ultrassonografia detectou um número maior de lesões nessas localizações, mas identificou número menor de lesões na pelve. Na análise comparativa global entre os dois métodos na detecção das lesões não houve diferença estatística significativa. O baixo custo, a boa tolerabilidade e o fácil acesso tornam a ultrassonografia instrumento diagnóstico valioso na endometriose profunda.

Sonography of endometriosis in infrequent sites

We reviewed the sonographic features of endometriosis in infrequent sites, including the abdominal wall, appendix, perineum, and bladder. Familiarity with the clinical setting and the sonographic appearance of endometriosis in both frequent and infrequent sites can help facilitate prompt, accurate diagnosis and treatment.

[Imaging of chronic pelvis pain]

This is a review of different diseases implicated in chronic pelvic pain (endometriosis, adenomyosis, pelvic varices, and pelvic chronic inflammatory disease) assessed by different imaging modalities (US, CT, MRI).

Modified virtual colonoscopy: a noninvasive technique for the diagnosis of rectovaginal septum and deep infiltrating pelvic endometriosis

In this study, we modified the standard virtual colonoscopy technique to diagnose deep infiltrating pelvic endometriosis. The following modifications were used: (1) insertion of a large obstetric tampon high into the vagina; (2) insertion of a Foley catheter into the rectum and insufflation with CO(2); and (3) scanning only the pelvis. We used a Toshiba Aquillion 64-multidetector computed tomography scanner coupled to a 3-D workstation. By employing various reconstruction modules such as endo-luminal fly-through, cubed volume, 2-D multiplanar reconstruction, 3-D transparent view, and 3-D volume-rendered and maximum intensity projection, we were able to demonstrate deep infiltrating pelvic endometriosis in bowel, urinary tract, and rectovaginal and retroperitoneal spaces.

Accuracy of transvaginal sonography and rectal endoscopic sonography in the diagnosis of deep infiltrating endometriosis

OBJECTIVES

To compare the accuracy of transvaginal sonography (TVS) and rectal endoscopic sonography (RES) for the diagnosis of deep infiltrating endometriosis (DIE), with respect to surgical and histological findings.

METHODS

This was a longitudinal study of 81 consecutive patients referred for surgical management of DIE, who underwent both TVS and RES preoperatively. The diagnostic criteria were identical for TVS and RES, and were based on visualization of hypoechoic areas in specific locations (uterosacral ligaments, vagina, rectovaginal septum and intestine). We calculated the sensitivity, specificity, predictive values and accuracy of TVS and RES for the diagnosis of DIE.

RESULTS

Endometriosis was confirmed histologically in 80/81 (98.7%) patients. Endometriomas and DIE were present in 43.2% and 97.5% of the women, respectively. For the diagnosis of DIE overall, TVS and RES, respectively, had a sensitivity of 87.3% and 74.7%, a positive predictive value of 98.6% and 98.3%, and an accuracy of 86.4% and 74%. For the diagnosis of uterosacral endometriosis, they had a sensitivity of 80.8% and 46.6%, a specificity of 75% and 50.0%, a positive predictive value of 96.7% and 89.5% and a negative predictive value of 30% and 9.3%. For the diagnosis of intestinal endometriosis, they had a sensitivity of 92.6% and 88.9%, a specificity of 100% and 92.6%, a positive predictive value of 100% and 96% and a negative predictive value of 87% and 80.6%.

CONCLUSION

TVS is apparently more accurate than is RES for predicting DIE in specific locations, and should thus be the first-line imaging technique in this setting.

Bowel endometriosis: presentation, diagnosis, and treatment

Bowel endometriosis opens a new frontier for the gynecologist, as it forces the understanding of a new anatomy, a new physiology, and a new pathology. Although some women with bowel endometriosis may be asymptomatic, the majority of them develop a variety of gastrointestinal complains. No clear guideline exists for the evaluation of patients with suspected bowel endometriosis. Given the fact that, besides rectal nodules, bowel endometriosis can not be diagnosed by physical examination, imaging techniques should be used. Several techniques have been proposed for the diagnosis of bowel endometriosis including double-contrast barium enema, transvaginal ultrasonography, rectal endoscopic ultrasonography, magnetic resonance imaging, and multislice computed tomography enteroclysis. Medical management of bowel endometriosis is currently speculative; expectant management should be carefully balanced with the severity of symptoms and the feasibility of prolonged follow-up. Several studies demonstrated an improvement in quality of life after extensive surgical excision of the disease. Bowel endometriotic nodules can be removed by various techniques: mucosal skinning, nodulectomy, full thickness disc resection, and segmental resection. Although the indications for colorectal resection are controversial, recent data suggest that aggressive surgery improves symptoms and quality of life.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the varied appearance of bowel endometriosis, recall that it is difficult to diagnose preoperatively, and explain that surgical treatment offers the best treatment in symptomatic patients through a variety of surgical techniques which is best accomplished with a team approach.

Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis

BACKGROUND

We compared the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of deep pelvic endometriosis (DPE), with respect to surgical and histological findings.

METHODS

Longitudinal study of 88 consecutive patients referred for surgical management of DPE, who underwent both MRI and RES pre operatively. The diagnostic criteria were identical for MRI and RES and were based on visualization of hypointense/hypoechoic areas in specific locations. DPE was diagnosed when at least one site was involved. We calculated the sensitivity, specificity, predictive values, accuracy and 95% confidence interval of MRI and RES for DPE.

RESULTS

DPE and endometriomas were present in 97.7 and 39.7% of women, respectively. The sensitivity, specificity and positive and negative predictive values of MRI and RES, respectively, were 84.8 and 45.6%, 88.8 and 40%, 98.5 and 87.8% and 40 and 8.5% for uterosacral endometriosis; 77.7 and 7.4%, 70% and 100, 85.3 and 100% and 89.7 and 70.9% for vaginal endometriosis and 88.3 and 90%, 92.8 and 89.3%, 96.4 and 94.7% and 78.8 and 80.6% for colorectal endometriosis.

CONCLUSIONS

MRI is more accurate than RES for the diagnosis of uterosacral and vaginal endometriosis, whereas the two methods are similarly accurate for colorectal endometriosis.

Endometriosis: the way forward

Endometriosis, a common cause of morbidity, affects 10% of women of reproductive age. In this review we focus on the new developments in pathogenesis, diagnosis and treatment options, reviewing the literature published about this enigmatic disorder over the past three years. More specifically, new theories of the pathogenesis of the syndrome of Sampson and Cullen are discussed. The new era of genomics may characterize endometriosis and transform clinical management of the disease. Literature suggesting that endometriosis may have an environmental origin is reviewed. New approaches to medical therapy of endometriosis have been developed, including the levonorgestrel-releasing intrauterine device, aromatase inhibitors, immunomodulatory drugs, angiogenesis inhibitors, selective estrogen and progesterone receptor modulators, and statins. Subfertility is another well-known result of endometriosis and often complex decisions must be made regarding management of the endometriosis patient who wishes to conceive. Laparoscopic surgery and assisted reproduction--with or without gonadotropin-releasing hormone-agonist treatment--are reviewed. Finally we speculate about new developments in the field of endometriosis in the coming three years.

From the archives of the AFIP: Inflammatory and nonneoplastic bladder masses: radiologic-pathologic correlation

Although the vast majority of bladder tumors are epithelial neoplasms, a variety of nonneoplastic disorders can cause either focal bladder masses or diffuse mural thickening and mimic malignancy. Some of these entities are rare and poorly understood such as inflammatory pseudotumor, which produces ulcerated, bleeding polypoid bladder masses. These masses may be large and have an extravesical component. Bladder endometriosis manifests as submucosal masses with characteristic magnetic resonance imaging features consisting of hemorrhagic foci and reactive fibrosis. Nephrogenic adenoma has no typical features, and pathologic evaluation is required for diagnosis. Although imaging features of malacoplakia are also nonspecific, characteristic Michaelis-Gutmann bodies are found at pathologic evaluation. The various types of cystitis (cystitis cystica, cystitis glandularis, and eosinophilic cystitis) require pathologic diagnosis. Bladder infection with tuberculosis and schistosomiasis produces nonspecific bladder wall thickening and ulceration in the acute phase and should be suspected in patients who are immunocompromised or from countries where these infections are common. The diagnosis of chemotherapy cystitis and radiation cystitis should be clinically evident, but imaging may be used to determine severity and to assess complications. Extrinsic inflammatory diseases such as Crohn disease and diverticulitis may be associated with fistulas to the bladder and focal bladder wall abnormality. The extravesical findings allow the diagnosis to be made easily. Finally, extrinsic masses arising from the prostate or distal ureter may cause filling defects, which can be confused with intrinsic bladder masses.

Bowel endometriosis: CT-enteroclysis

Although several radiological techniques have been used for the diagnosis of bowel endometriosis, no gold standard is currently established. We used multislice computerized tomography (CT) combined with the distention of the colon by rectal enteroclysis (MSCTe) for the diagnosis of bowel endometriosis. Following bowel preparation, pharmacological hypotonicity, retrograde colonic distention by water enteroclysis, and intravenous injection of iodinated contrast medium, a single volumetric acquisition of the abdomen is performed. MSCTe findings suggestive of bowel endometriosis are the presence of solid nodules with positive enhancement, contiguous or penetrating the colonic wall. When endometriotic lesions are detected, the degree of infiltration of the intestinal wall can be estimated; however, the depth infiltrated by nodules reaching the submucosa may be underestimated. MSCTe is well tolerated by the patients. The strength of MSCT consists in the high spatial resolution; volumetric data acquired by using thin slices provide isotropic voxels and multiplanar reconstructions have a quality comparable with that of the original axial scans. The potential of MSCTe for the diagnosis of bowel endometriosis relies on the fact that the serosal, muscular, and mucosal layers of the bowel wall can be evaluated.

The role of magnetic resonance imaging in minimal access surgery

PURPOSE OF REVIEW

Magnetic resonance imaging is commonly used for gynaecological malignancies, but also is increasingly used for the investigation of benign gynaecological complaints. This review summarizes the current evidence regarding its use as an adjunct to minimal access surgery for endometriosis, adenomyosis, adhesions and fibroids.

RECENT FINDINGS

Magnetic resonance imaging appears to be equal in efficacy to ultrasound for the diagnosis of both fibroids and endometriosis, and perhaps superior for the diagnosis of adenomyosis. It is extremely useful for the preoperative investigation of severe endometriosis, especially recto-vaginal disease. Milder endometriosis is, however, still difficult to diagnose by either ultrasound or magnetic resonance imaging. Magnetic resonance imaging can also be helpful for the detection of adhesions, pelvic collections, congenital defects and fibroids. It is also useful following fibroid embolization.

SUMMARY

Currently, it is not cost-effective to use magnetic resonance imaging as the modality of first choice when investigating pelvic pain and or menstrual disorders. If preoperative patients are carefully selected, however, it can substantially reduce surgical morbidity by using it to diagnose severe endometriosis and adhesions which may lead to cost savings overall.

Multislice CT enteroclysis in the diagnosis of bowel endometriosis

This prospective study aims to evaluate the efficacy of multislice computed tomography combined with colon distension by water enteroclysis (MSCTe) in determining the presence and depth of bowel endometriotic lesions. Ninety-eight women with symptoms suggestive of colorectal endometriosis underwent MSCTe; locations, number of nodule/s, size of the nodule/s and depth of bowel wall infiltration were determined. Independently from the findings of MSCTe, all women underwent laparoscopy. MSCTe findings were compared with surgical and histological results. Abnormal findings suggestive of bowel endometriotic nodules were detected by MSCTe in 75 of the 76 patients with bowel endometriosis. MSCTe identified 110 (94.8%) of the 116 bowel endometriotic nodules removed at surgery; 6 nodules missed at MSCTe were located on the rectum. MSCTe correctly determined the degree of infiltration of the bowel wall in all of the 34 serosal bowel nodules identified at MSCTe. In six nodules reaching the submucosa, the depth of infiltration was underestimated by MSCTe. MSCTe had a sensitivity of 98.7%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 95.7% in identifying women with bowel endometriosis. MSCTe is effective in determining the presence and depth of bowel endometriotic lesions.