Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy

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

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

Nodular image in the appendix observed on ultrasound: endometriosis or neuroendocrine neoplasia?

Objective

To evaluate the association between clinical and imaging with surgical and pathological findings in patients with suspected neuroendocrine tumor of appendix and/or appendix endometriosis.

Methods

Retrospective descriptive study conducted at the Teaching and Research Institute of Hospital Israelita Albert Einstein, in which medical records and databases of patients with suspected neuroendocrine tumor of appendix and/or endometriosis of appendix were analyzed by imaging.

Results

Twenty-eight patients were included, all of which had some type of appendix alteration on the ultrasound examination. The pathological outcome of the appendix found 25 (89.3%) lesions compatible with endometriosis and three (10.7%) neuroendocrine tumors. The clinical findings of imaging and surgery were compared with the result of pathological anatomy by means of relative frequency.

Conclusion

It was possible to observe a higher prevalence of appendix endometriosis when the patient presented more intense pain symptoms. The image observed on ultrasound obtained a high positive predictive value for appendicular endometriosis.

Evaluation of HLA-DQ2 and HLA-DQ8 haplotypes in patients with endometriosis, A case-control study

OBJECTIVE

To evaluate the relationship between genetic haplotypes associated with celiac disease (Human Leucocyte Antigen [HLA] DQ2 and DQ8) with the diagnosis, clinical presentation, and location of endometriosis in Brazilian women.

METHOD

A retrospective cross-sectional study, was conducted in a Tertiary hospital.

PATIENTS

Women aged 18-50 years who underwent HLA-DQ2 and HLA-DQ8 haplotype analysis.

INTERVENTION

The patients were divided into endometriosis and control groups and evaluated for symptoms; endometriosis location, American Society for Reproductive Medicine (ASRM) stage, and the presence of anti-tissue transglutaminase IgA (anti-TgA), HLA-DQ2, and HLA-DQ8 markers.

RESULTS

A total of 434 consecutive patients with (n = 315) and without (n = 119) endometriosis were included. Pain and infertility were more frequent in the endometriosis group than in the control group. The presence of HLA-DQ2, HLA-DQ8, and anti-TgA was similar between both groups. The presence of HLA-DQ2 and HLA-DQ8 markers did not differ based on age, pain symptoms, ASRM stage, or endometriosis location.

CONCLUSION

Although there are similarities in inflammatory markers and pathophysiology between celiac disease and endometriosis, this study found no significant associations in the presence of HLA-DQ2 or HLA-DQ8 haplotypes and endometriosis.

Pilot study of treatment of patients with deep infiltrative endometriosis with methotrexate carried in lipid nanoparticles

OBJECTIVE

Previously, lipid nanoparticles (LDE) injected in women with endometriosis were shown to concentrate in the lesions. Here, the safety and feasibility of LDE carrying methotrexate (MTX) to treat deep infiltrating endometriosis was tested.

DESIGN

Prospective pilot study.

SETTING

Perola Byington Hospital Reference for Women's Health.

SUBJECTS

Eleven volunteers (aged 30-47 years, BMI 26.15 ± 6.50 kg/m2) with endometriosis with visual analog scale pelvic pain scores (VAS) > 7 and rectosigmoid lesions were enrolled in the study.

INTERVENTION

Three patients were treated with LDE-MTX at single intravenous 25 mg/m2 dose of MTX and eight patients with two 25 mg/m2 doses with 1-week interval.

MAIN OUTCOME MEASURES

Clinical complaints, blood count, and biochemistry were analyzed before treatment and on days 90, 120, and 180 after LDE-MTX administration. Endometriotic lesions were evaluated by pelvic and transvaginal ultrasound (TVUS) before treatment and on days 30 and 180 after LDE-MTX administration.

RESULTS

No clinical complaints related with LDE-MTX treatment were reported by the patients, and no hematologic, renal, or hepatic toxicities were observed in the laboratorial exams. FSH, LH, TSH, free T4, anti-Müllerian hormone, and prolactin levels were also within normal ranges during the observation period. Scores for deep dyspareunia (p < 0.001), chronic pelvic pain (p = 0.008), and dyschezia (p = 0.025) were improved over the 180-day observation period. There was a non-significant trend for reduction of VAS scores for dysmenorrhea. Bowel lesions by TVUS were unchanged. No clear differences between the two dose levels in therapeutic responses were observed.

CONCLUSION

Results support the safety and feasibility of using LDE-MTX in women with deep infiltrating endometriosis as a novel and promising therapy for the disease. More prolonged treatment schemes should be tested in future placebo-controlled studies aiming to establish the usefulness of this novel nanomedicine approach.

Endometriosis Predictive Models Based on Self-Assessment Questionnaire, Evidence from Clinical Examination or Imaging Findings: A Narrative Review

OBJECTIVE

The aim of this narrative review is to evaluate existing questionnaires on predictive models for endometriosis. These symptom-based models have the potential to serve as screening tools for adult women to detect endometriosis.

DATA SOURCES

A comprehensive search of PubMed and Embase databases was conducted to identify studies on endometriosis screening.

SELECTION OF STUDIES

The search targeted predictive models for endometriosis localisation, bowel involvement, need for bowel surgery and fertility. Due to the heterogeneity identified, a systematic review was not possible. A total of 23 studies were identified.

DATA EXTRACTION AND SYNTHESIS

Among these studies, twelve included measures for general endometriosis, two targeted specific sites, four focused on deep infiltrating endometriosis (DIE), and three addressed the need for endometriosis-related bowel surgery. Many measures combined clinical, imaging and laboratory tests with patient questionnaires. Validation of these models as screening tools was lacking in all studies, as the focus was on diagnosis rather than screening.

CONCLUSION

This review did not identify any fully validated, symptom-based questionnaires for endometriosis screening in adult women. Substantial validation work remains to establish the efficacy of such tools.

Vaginal leiomyoma: Advantages of clinical sonovaginography and ultrasound dynamic evaluation of uterine cervix-related lesions

Evaluation of vaginal leiomyoma by dynamic transvaginal ultrasound improves the diagnosis, with the impact on surgical planning, and surgical outcomes. Sonovaginography using three-dimensional ultrasound allows the assessment of spatial relationship between the cervix and the tumor.

Robotic multiple sigmoid and rectal mucosa skinning in a multicentric deep infiltrating bowel endometriotic nodules: a case report

Endometriosis is a benign gynecological disease characterized by the presence of endometrial tissue outside the uterus. The eradication of non-gynecological localizations represents the real surgical challenge. A 29-year-old woman underwent robotic surgery with the Da Vinci system (Intuitive Surgical Inc.) for a diagnosis of stage IV deep endometriosis. The patient presented with 5 cm left ovarian endometrioma, an infiltration of the left posterior parametrium, and bilateral ureteral endometriosis. Once inside the pelvic cavity, deep intestinal infiltrating endometriosis implants were confirmed as triple, multicentric, and multifocal lesions, affected distal sigmoid, rectosigmoid junction, and upper rectum. An expert multiple excision, sparing the intestinal mucosa, was performed. To our knowledge, this is the first description of a multiple robotic shaving of multicentric endometriotic intestinal lesions. After the surgery, a normal diet was quickly restored, accelerating the recovery of the physiological peristalsis and the overall recovery time.

[Performance of an Ultrasound Based Endometriosis Staging System (UBESS) for predicting rectal involvement and type of surgical procedure in patients with digestive endometriosis]

OBJECTIVE

Preoperative assessment of rectal damage in digestive endometriosis requires rectal endoscopic ultra-sonography an invasive exam that is not well received by the patients. A standardized approach using an Ultrasound-Based Endometriosis Staging System (UBESS)could be an interesting tool in this indication. This article aims to evaluate the performance of UBESS in the prediction of rectal involvement and the type of surgical procedure.

MATERIALS AND METHODS

This monocentric retrospective study was conducted on patients with rectal endometriosis who underwent a curative surgical procedure, evaluated by UBESS ultrasound between January 2016 and December 2019 at the Poissy referral centre. The main analysis of the study was to assess the adequacy of the UBESS ultrasound stage, the presence of rectal involvement during surgery and the surgical technique required. The secondary objective was to determine the correlation between UBESS stages and RCOG levels of surgical difficulty.

RESULTS

A total of one hundred and twenty-two patients were included and one hundred were analysed. Of these, thirty-nine had rectal involvement. There was a statistically significant association between the UBESS stage and the presence of a digestive lesion(P<0.0001). The ultrasound's parameters of thickness(P=0.0007), width(P=0.0082) and volume(P=0.0013) of the digestive lesion were significantly correlated with the extent of the surgical procedure. The correlation between the UBESS and RCOG classifications was very weak.

CONCLUSION

UBESS is a powerful diagnostic tool for digestive damage allowing to give clear information to patients before surgery and optimizing the management plan of the surgery.

Robotic-assisted sigmoidectomy with intracorporeal anastomosis and endoscopic management of deep infiltrating intestinal endometriosis

Deep endometriosis, defined as external adenomyosis, is a late stage of endometriosis. Associated with very severe pain, in addition to probably being a cofactor of infertility, with a low prevalence, the diagnosis is integrated by high clinical suspicion and confirmed with imaging studies. Deep infiltration can reach sigmoid colon, which would have surgical indication as resolving treatment. We report the case of deep infiltrating endometriosis affecting sigmoid colon of a 42-year-old woman, who was diagnosed with colicky pain in the left lower quadrant and chronic constipation. Colonoscopy revealed a 90% stenosis in the proximal portion of sigmoid colon, as well as mural thickening proximal to the site of stenosis, reported by computed tomography with oral contrast, for which it was decided to perform robot-assisted sigmoidectomy, with a 6-month follow-up and with imaging control, patient continues asymptomatic and without the presence of lesions suggestive of recurrence, and there is no functional impairment.

Evaluation and management of endometriosis

The initial diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The pelvic examination should include a speculum examination and vaginal palpation. Mobility, fixation and/or tenderness of the uterus and site-specific tenderness in the pelvis should be evaluated. Transvaginal ultrasound and pelvic magnetic resonance imaging are recommended to evaluate the extent of the endometriosis and to determine whether any urinary tract or bowel procedures might also be required during surgical resection. Quality of life should be assessed by using the Endometriosis Health Profile-30, its short version EHP-5 or the generic quality of life questionnaire SF-36. Management of endometriosis is recommended when it has a functional impact (pain, infertility) or causes organ dysfunction. Many gynecological societies have published different guidelines for the evaluation and management of endometriosis. However, the complexity of this disease together with the different available treatments lead to significant discrepancies between the recommendations. Postmenopausal endometriosis should be considered when a patient has a history of symptoms before menopause including dysmenorrhea, dyspareunia, dyschezia, infertility and chronic pelvic pain. Malignant transformation of endometriosis is estimated to occur in about 0.7-1.6% of women affected by endometriosis. Endometriosis is associated with an increased risk of ovarian cancer, specifically clear cell, endometrioid and low-grade serous types.

Evaluation of an e-learning program for the diagnosis of rectosigmoid endometriosis with rectal water contrast transvaginal ultrasonography (rectosonography)

This study aimed to evaluate the value of an e-learning program for the diagnosis of rectosigmoid endometriosis lesions using rectal water contrast transvaginal ultrasonography (rectosonography/RSG). Theoretical RSG training using videos with a commentary was offered online to healthcare professionals involved in ultrasound screening for endometriosis. A test (without correction) with 24 RSG video loops was used to assess the participants' baseline level before the training and their improvement afterwards. If the success rate post-training was below 80 %, the participant could start over with another series of 24 videos. Between February and June 2020, thirty participants took the training course (of which 80 % were obstetrics-gynaecology residents). The e-learning program resulted in a significant performance increase in the diagnosis of rectosigmoid endometriosis lesions, with a higher test success rate after the training compared to before (74.4 % and 63.6 % respectively; +10.8 %; 95 % CI [6,6; 15]; p < 0.001). Significant improvement was also observed regarding the overall skills involved in the ultrasound diagnosis of deep infiltrating endometriosis (+9.2 %; p < 0.001), the accurate diagnosis of the height of bowel lesions (+14.7 %; p < 0.001) and uterosacral ligament lesions (+8%; p < 0.005). In conclusion, our e-learning program led to a significant improvement of the diagnostic performance of digestive endometriosis using transvaginal ultrasound with intrarectal water contrast (rectosonography). Adding feedback to the post-test video loops could further increase the efficacy of the e-learning training.

Ultrasound prediction of segmental bowel resection in women with rectovaginal endometriosis: a single centre experience

STUDY OBJECTIVE

To retrospectively evaluate the ability of routinely collected pre-operative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis.

DESIGN AND SETTING

Patients at University College London Hospital (UCLH) who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (BSGE) database. Imaging data were collected and analysed to determine associations with the requirement for bowel resection.

PATIENTS

We evaluated 228 consecutive women undergoing bowel surgery (shave, disc or segmental resection) for rectovaginal endometriosis.

INTERVENTIONS

The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection and segmental resection of the bowel. All patients underwent a pre-operative transvaginal ultrasound to assess the extent of endometriosis.

MEASUREMENTS AND MAIN RESULTS

There were 206 (90.4%) rectal shaves, 2 (0.9%) disc resections, and 20 (8.8%) segmental bowel resections. A multivariable analysis demonstrated an association between bowel resection and two or more nodules located in the rectovaginal space (odds ratio 6.85, 95% CI 1.37, 34.2), nodules in the vesico-uterine pouch (odds ratio 5.87, 95% CI 1.03, 33.3), and increasing nodule size (odds ratio 2.39 per 1cm increase per 1cm diameter increase, 95% CI 1.56, 3.64).

CONCLUSION

Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counselling and surgical planning in the pre-operative setting for women with rectovaginal endometriosis.

Cognitive Behavioral Therapy in Endometriosis, Psychological Based Intervention: A Systematic Review

INTRODUCTION

 Endometriosis is an inflammatory disease that affects women of reproductive age, causing pain and the possibility of infertility. Endometriosis was associated to low life quality and research shows the impact of endometriosis in several areas of life, justifying how these patients are more likely to develop depression, anxiety, and stress.

OBJECTIVE

 The aim of the present systematic review was to explore the field of psychology in endometriosis, identifying studies that used the cognitive behavioral therapy technique as a treatment for endometriosis and chronic pelvic pain.

METHODS

 The keywords used were Endometriosis and Behavioral Therapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy; Mental Health; Psychological Techniques; Psychology; Psychotherapy; Mental Health Services; and the search was performed in the following databases: PubMed/Medline, Scielo, Lilacs, and Capes. The study followed the PRISMA guidelines and all studies whose intervention strategy used was related to cognitive-behavioral therapy were considered.

RESULTS

 Of the 129 articles found, only 5 were selected, and it was possible to identify that the psychological intervention whose approach brought cognitive-behavioral therapy techniques promoted a decrease in the sensation of pain, improvements in the scores of depression and stress, and significant changes in aspects of quality of life such as vitality, physical and social functioning, emotional well-being, control, and autonomy.

CONCLUSION

 Cognitive-behavioral therapy can be very promising to take care of the emotional side of those who have endometriosis However, the present systematic review highlights the need to develop more structured studies with consistent, clear and replicable methods to reach a psychological intervention protocol for patients who live with this gynecological-physical-emotional condition.

Preoperative Imaging in Patients with Deep Infiltrating Endometriosis (DIE): An Important aid in Predicting Depth of Infiltration in Rectosigmoid Disease

STUDY OBJECTIVE

To determine the diagnostic accuracy of specialist transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histological specimens obtained at surgery.

DESIGN

A retrospective analysis, which met the STARD (2015) guidelines for a diagnostic accuracy study.

SETTING

Tertiary teaching hospital.

PATIENTS

194 cases who underwent preoperative discussion at the Gynaecological Endosurgery Unit multidisciplinary meeting (MDM) between January 2012 and December 2019 were eligible for inclusion.

INTERVENTIONS

Retrospective assessment of the accuracy of TVUS and MRI in predicting histological depth of rectosigmoid DIE following operative management.

MEASUREMENTS AND MAIN RESULTS

135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, 63 had no rectosigmoid surgery. Of the 52 patients with full thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histological depth in 48 (92%) cases (sensitivity 94%, specificity 50%, positive predictive values (PPV) 97.9%, negative predictive value (NPV) 25.0%; area under the receiver operating curves (AUROC) 0.720, 95%CI: 0.229, 1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity 93.6%, specificity 50.0%, PPV 97.8%, NPV 25.0%; AUROC 0.718, 95%CI: 0.227, 1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity 86.4%, specificity 100%, PPV 100%, NPV 14.2).

CONCLUSION

Specialised performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement and their use is justified in the preoperative planning of these gynaecological surgeries.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN SIZE DURATION

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

PARTICIPANTS/MATERIALS SETTING METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTERESTS

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

REGISTRATION NUMBER

Prospective registration with PROSPERO (CRD42017059872) was obtained.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.

AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score

STUDY OBJECTIVE

To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.

DESIGN

Multicenter study of patients treated at 3 recognized endometriosis centers.

SETTING

Three specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.

PATIENTS

Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.

INTERVENTIONS

Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.

MEASUREMENTS AND MAIN RESULTS

A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.

CONCLUSION

The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.

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

OBJECTIVES

To review the accuracy of different imaging modalities for the detection of rectosigmoid deep endometriosis (DE) in women with clinical suspicion of endometriosis, and to determine the optimal modality.

METHODS

A search was conducted using PubMed, MEDLINE, Scopus, EMBASE and Google Scholar to identify studies using imaging to evaluate women with suspected DE, published from inception to May 2020. Studies were considered eligible if they were prospective and used any imaging modality to assess preoperatively for the presence of DE in the rectum/rectosigmoid, which was then correlated with the surgical diagnosis as the reference standard. Eligibility was restricted to studies including at least 10 affected and 10 unaffected women. The QUADAS-2 tool was used to assess the quality of the included studies. Mixed-effects diagnostic meta-analysis was used to determine the overall pooled sensitivity and specificity of each imaging modality for rectal/rectosigmoid DE, which were used to calculate the likelihood ratio of a positive (LR+) and negative (LR-) test and diagnostic odds ratio (DOR).

RESULTS

Of the 1979 records identified, 30 studies (3374 women) were included in the analysis. The overall pooled sensitivity and specificity, LR+, LR- and DOR for the detection of rectal/rectosigmoid DE using transvaginal sonography (TVS) were, respectively, 89% (95% CI, 83-92%), 97% (95% CI, 95-98%), 30.8 (95% CI, 17.6-54.1), 0.12 (95% CI, 0.08-0.17) and 264 (95% CI, 113-614). For magnetic resonance imaging (MRI), the respective values were 86% (95% CI, 79-91%), 96% (95% CI, 94-97%), 21.0 (95% CI, 13.4-33.1), 0.15 (95% CI, 0.09-0.23) and 144 (95% CI, 70-297). For computed tomography, the respective values were 93% (95% CI, 84-97%), 95% (95% CI, 81-99%), 20.3 (95% CI, 4.3-94.9), 0.07 (95% CI, 0.03-0.19) and 280 (95% CI, 28-2826). For rectal endoscopic sonography (RES), the respective values were 92% (95% CI, 87-95%), 98% (95% CI, 96-99%), 37.1 (95% CI, 21.1-65.4), 0.08 (95% CI, 0.05-0.14) and 455 (95% CI, 196-1054). There was significant heterogeneity and the studies were considered methodologically poor according to the QUADAS-2 tool.

CONCLUSIONS

The sensitivity of TVS for the detection of rectal/rectosigmoid DE seems to be slightly better than that of MRI, although RES was superior to both. The specificity of both TVS and MRI was excellent. As TVS is simpler, faster and more readily available than the other methods, we believe that it should be the first-line diagnostic tool for women with suspected DE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Genomics of Endometriosis: From Genome Wide Association Studies to Exome Sequencing

This review aims at better understanding the genetics of endometriosis. Endometriosis is a frequent feminine disease, affecting up to 10% of women, and characterized by pain and infertility. In the most accepted hypothesis, endometriosis is caused by the implantation of uterine tissue at ectopic abdominal places, originating from retrograde menses. Despite the obvious genetic complexity of the disease, analysis of sibs has allowed heritability estimation of endometriosis at ~50%. From 2010, large Genome Wide Association Studies (GWAS), aimed at identifying the genes and loci underlying this genetic determinism. Some of these loci were confirmed in other populations and replication studies, some new loci were also found through meta-analyses using pooled samples. For two loci on chromosomes 1 (near CCD42) and chromosome 9 (near CDKN2A), functional explanations of the SNP (Single Nucleotide Polymorphism) effects have been more thoroughly studied. While a handful of chromosome regions and genes have clearly been identified and statistically demonstrated as at-risk for the disease, only a small part of the heritability is explained (missing heritability). Some attempts of exome sequencing started to identify additional genes from families or populations, but are still scarce. The solution may reside inside a combined effort: increasing the size of the GWAS designs, better categorize the clinical forms of the disease before analyzing genome-wide polymorphisms, and generalizing exome sequencing ventures. We try here to provide a vision of what we have and what we should obtain to completely elucidate the genetics of this complex disease.

Structured MRI reporting increases completeness of radiological reports and requesting physicians' satisfaction in the diagnostic workup for pelvic endometriosis

PURPOSE

MRI plays an important role in the diagnosis and surgical planning of pelvic endometriosis (PE), and imaging reports should contain all relevant information (completeness). As structured reports are being increasingly utilized, we aimed to evaluate whether structured MRI reporting increases the quality of reports regarding completeness and, consequently, their perceived value by gynecologists, in comparison to free-text reports. We also aimed to compare the diagnostic performance of both formats.

METHODS

We retrospectively included 28 consecutive women with histologically proven PE who underwent MRI within one month before surgery. Two abdominal radiologists (Rd1/Rd2, 3y/12y experience), blinded to clinical and surgical data, individually elaborated free-text reports and, four months later, structured reports. Completeness (defined as description of six key anatomical sites deemed essential for surgical planning in a consensus of four-blinded external experts) and diagnostic performance (sensitivity and specificity) by site (histology as reference) were compared between reports using the McNemar test. The satisfaction of gynecologists was compared using the marginal homogeneity test.

RESULTS

Structured reporting increased completeness for both Rd1 (rectosigmoid, retrocervical/uterosacral ligament, vagina, and ureter) and Rd2 (vagina, ureter, and bladder) (p < 0.05), without compromising sensitivity or specificity at any of the evaluated sites. Gynecologists' satisfaction was superior with structured reports in most comparisons.

CONCLUSION

Structured MRI reports perform better in fully documenting essential features of PE and are similar in terms of diagnostic performance, therefore having higher potential for surgical planning. Gynecologists found them easier to assess and were more satisfied with the information provided by structured reports.

Systematic evaluation of endometriosis by transvaginal ultrasound can accurately replace diagnostic laparoscopy, mainly for deep and ovarian endometriosis

STUDY QUESTION

What is the sensitivity and the specificity of preoperative transvaginal ultrasound with bowel preparation (TVUS-BP) compared to diagnostic laparoscopy (DL) for the identification of ovarian and deep sites of endometriosis?

SUMMARY ANSWER

DL was able to detect retrocervical, ovarian, and bladder endometriosis with similar sensitivity and specificity as TVUS-BP, whereas for vaginal and rectosigmoid endometriosis, DL had lower sensitivity and specificity than TVUS-BP.

WHAT IS KNOWN ALREADY

TVUS-BP is a non-invasive examination with good accuracy for diagnosing ovarian and deep endometriosis. DL is expensive and can lead to surgical complications.

STUDY DESIGN, SIZE, DURATION

This prospective study included a total of 120 consecutive patients who underwent surgery for suspected endometriosis with preoperative imaging (TVUS-BP), including a video of the laparoscopic procedure, between March 2017 and September 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two radiologists performed preoperative TVUS-BP using the same protocol for diagnosing endometriosis. Two surgeons, who were blinded to the results of the preoperative imaging and clinical data, reviewed the surgical videos from the entry of the abdominal cavity until the surgeon finalized a complete and systematic review prior to beginning any dissection (considered as a DL). A data sheet was used by surgeons and radiologists to record the sites and size of disease involvement, the American Society for Reproductive Medicine (ASRM) stage, and the Enzian score. The surgical visualization of endometriosis lesions that were confirmed by histological analysis was the gold standard.

MAIN RESULTS AND THE ROLE OF CHANCE

DL was able to detect retrocervical, ovarian, and bladder endometriosis with similar sensitivity and specificity as TVUS-BP. DL was not able to detect vaginal endometriosis (sensitivity and specificity 0%): this is compared to a sensitivity and specificity of 85.7% and 99.1%, respectively with the utilization of a preoperative TVUS-BP. In addition, DL was notably poor at detecting rectosigmoid endometriosis, with a sensitivity of 3.7-5.6%, and this compares to 96.3% sensitivity with utilization of a preoperative TVUS (P < 0.001). For the ASRM stage, TVUS-BP results were highly correlated with the degree of endometriosis and pouch of Douglas (POD) obliteration (weighted Kappa of 0.867 and 0.985, respectively). For the Enzian score, there was a substantial correlation between TVUSP-BP and DL for compartment A (weighted Kappa = 0.827), compartment B (weighted Kappa = 0.670), and compartment C (weighted kappa = 0.814).

LIMITATIONS, REASONS FOR CAUTION

The number of participants included may be a limitation in this study and, as the evaluators were blinded to the physical exam, the DL accuracy could be underestimated. As biopsies of pelvic organs were obtained only if there was a suspicion of endometriosis, the gold standard was not always applicable. This aspect could underestimate the prevalence of lesions and overestimate the sensitivity and the specificity of both the TVUS-BP and the DL.

WIDER IMPLICATIONS OF THE FINDINGS

Preoperative TVUS-BP was accurate in identifying all sites of ovarian and deep endometriosis that were evaluated. It had significantly higher sensitivity than DL in detecting rectosigmoid endometriosis and predicting intraoperative ASRM staging and the Enzian score. These results suggest that TVUS-BP can replace DL for the diagnosis and treatment planning for patients with ovarian and deep endometriosis.

STUDY FUNDING/COMPETING INTEREST(S)

The authors declare no source of funding or conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Overview of miRNAs for the non-invasive diagnosis of endometriosis: evidence, challenges and strategies. A systematic review

OBJECTIVE

The aim of the study was to assess the evidence on miRNAs as biomarkers for the diagnosis of endometriosis, as well as to provide insights into the challenges and strategies associated with the use of these molecules as accessible tools in clinical practice.

METHODS

Systematic review conducted on PubMed®, Latin American and Caribbean Health Sciences Literature (LILACS), MEDLINE® and Web of Science databases using the search terms endometriosis (all fields) AND miRNA (all fields), evaluating all publication up to May 2019.

RESULTS

Most miRNAs found to be dysregulated in this study were harvested from tissue samples, which precludes their use as a non-invasive diagnostic test. However, differential expression of 62 miRNAs was reported in samples that may be used for non-invasive diagnosis of endometriosis, such as blood, serum and plasma.

CONCLUSION

Despite the identification of several candidates, studies are investigatory in nature and have been conducted with small number of samples. Also, no particular miRNA has been validated for diagnostic purposes so far. Studies based primarily on biological samples and applicable to translational research are warranted. Large databases comprising information on sample type and the use of saliva and vaginal fluid for miRNAs identification may prove essential to overcome current barriers to diagnosis of endometriosis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intestinal endometriotic nodules with a length greater than 2.25 cm and affecting more than 27% of the circumference are more likely to undergo segmental resection, rather than linear nodulectomy

Study objective

To analyze the efficacy of intestinal ultrasonography with bowel preparation (TVUSBP) for endometriosis mapping in evaluating intestinal endometriosis to choose the surgical technique (segmental resection or linear nodulectomy) for treatment.

Design

Cross-sectional observational study.

Setting

University Hospital—Center for Advanced Endoscopic Gynecologic Surgery from April 2010 to November 2014.

Patient(s)

One hundred and eleven women with clinically suspected endometriosis and intestinal endometriotic nodule or intestinal adherence in TVUSBP for endometriosis mapping.

Intervention(s)

All patients with suspected endometriosis underwent TVUSBP for endometriosis mapping prior to videolaparoscopy for complete excision of endometriosis foci, including intestinal foci, using the linear nodulectomy or segmental resection techniques, depending on the characteristics of the intestinal lesion with confirmation of endometriosis on anatomopathological examination.

Measurements and main results

Preoperative ultrasonographic assessment of the length of the intestinal nodule, circumference of the intestinal loop affected by the endometriotic lesion, distance from the anal verge and intestinal wall layers infiltrated by endometriosis, as well as other endometriosis sites. Of the 111 patients who participated in the study, 63 (56.7%) presented intestinal endometriotic nodules in ultrasonography, performed by a single examiner (A.L.A.N.), and underwent intestinal surgical treatment of deep endometriosis—linear nodulectomy or segmental resection. The analysis of the receiver operating characteristic (ROC) curve showed that a longitudinal length of the intestinal nodule of 2.25 cm and a loop circumference of 27% are cutoff points separating linear nodulectomy from segmental resection techniques for excising intestinal endometriosis. The information obtained by TVUSBP helps the surgeon and patient, in the preoperative period, to select the surgical technique to be performed for resection of intestinal endometriosis and plan the surgical procedure while taking into account postoperative morbidity.

Bowel preparation prior to transvaginal ultrasound improves detection of rectosigmoid deep infiltrating endometriosis and is well tolerated: prospective study of women with suspected endometriosis without surgical criteria

OBJECTIVES

To analyze the effect of bowel preparation prior to transvaginal ultrasound (TVS) examination on the detection of bowel involvement and the description of rectosigmoid nodules of deep infiltrating endometriosis (DIE), and to evaluate patient tolerance of bowel preparation.

METHODS

This was a prospective study of paired data obtained between September 2015 and March 2016 from a cohort of women referred, on suspicion of DIE but without surgical criteria, to the endometriosis unit of a tertiary university hospital. In all patients, the wall of the rectum and lower sigmoid colon was evaluated by two TVS examinations: the first was performed without bowel preparation and the second was done after the patient had followed a 3-day low-residue diet and received two 250-mL enemas, one the night before TVS and the second 1-3 h before the examination. The presence of adhesions, number and size of rectosigmoid nodules, deepest layer of the rectum affected, percentage of the circumference of the bowel affected and distance from the most caudal part of the bowel nodule to the anal verge were determined. Patient tolerance to bowel preparation was assessed using a 5-point Likert scale, in which 1 represented 'very well tolerated' and 5 represented 'very poorly tolerated'.

RESULTS

The mean ± SD age of the 110 patients included in the study was 36.8 ± 5.07 years. As many as 55% of those identified during the first examination (TVS alone) as having adhesions were identified at the second examination (TVS with prior bowel preparation) as having rectosigmoid nodules, and 22 additional nodules were observed on TVS following bowel preparation. These newly detected rectosigmoid nodules, initially assessed mainly as adhesions, were smaller and more superficial compared with the nodules detected on TVS alone, or located in the anterior sigmoid wall. Patient tolerance overall to bowel preparation scored a mean of 1.81 on the 5-point Likert scale.

CONCLUSIONS

Bowel preparation is well tolerated by patients. When bowel preparation is performed before TVS, the detection of small and superficial nodules and those in the anterior sigmoid wall is improved, allowing more detailed description of these nodules in patients with suspected endometriosis. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Infertility in women with bowel endometriosis: first-line assisted reproductive technology results in satisfactory cumulative live-birth rates

OBJECTIVE

To evaluate the assisted reproductive technology (ART) cumulative live-birth rate (LBR) in a cohort of bowel endometriosis patients with no prior history of surgery for endometriosis.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENT(S)

One hundred and one consecutive infertile bowel-endometriosis patients with no prior history of surgery for endometriosis in whom the diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging.

INTERVENTION(S)

First-line ART.

MAIN OUTCOME MEASURE(S)

Cumulative LBR, with statistical analysis via Kaplan Meier method with a "conservative" method, whereby it was assumed that no live births took place for patients who did not return.

RESULT(S)

Between January 2016 and December 2018, 101 bowel endometriosis patients underwent 176 ART cycles. The mean number of deep-infiltrating endometriosis lesions per patient was 3 ± 0.9, with a mean number of bowel lesions of 1.3 ± 0.6. Seventy-three percent of the patients had associated endometriomas, and 88.1% had associated adenomyosis. Overall, the cumulative LBR after four ART cycles was 64.4%, using the conservative Kaplan-Meier method.

CONCLUSION(S)

The ART cumulative LBR was very satisfactory (64.4%) in bowel endometriosis patients with no prior history of surgery for endometriosis. In light of these data, clinicians should carefully weigh the pros and cons before systematically referring infertile bowel endometriosis patients to fertility-preserving surgery because as first-line ART appears to offer satisfactory results.

Transvaginal Sonographic Imaging and Associated Techniques for Diagnosis of Ovarian, Deep Endometriosis, and Adenomyosis: A Comprehensive Review

Imaging of endometriosis and in particular deep endometriosis (DE) is crucial in the clinical management of women facing this debilitating condition. Transvaginal sonography (TVS) is the first-line imaging method and magnetic resonance imaging (MRI) may provide supplemental information. However, the delay in diagnosis of up to 10 years and more is of concern. This problem might be overcome by simple steps using imaging with emphasis on TVS and referral to tertiary care. Finally, TVS is crucial in mapping extent and location of disease in planning surgical therapy and counseling women regarding various therapeutic options. This review presents the available data on imaging of endometriosis with a focus on TVS and MRI for DE, adenomyosis, and ovarian endometriomas including endometriomas in pregnancy as well as the use of "soft markers." The review presents an approach that is in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement.

Neuroendocrine appendiceal tumor and endometriosis of the appendix: a case report

INTRODUCTION

Endometriosis of the appendix is very uncommon, accounting for only about 1% of all cases of endometriosis. However, endometriosis is found in the appendix in approximately 8-13% of patients with deep infiltrating endometriosis and is particularly common in patients with severe forms of deep infiltrating endometriosis. Neuroendocrine tumors are the most common neoplasms of the appendix and may be misdiagnosed when there are multiple endometriosis lesions in the pelvis.

CASE PRESENTATION

We describe a case of a Caucasian patient with deep infiltrating endometriosis with rectal involvement, retrocervical lesions, and a right ovarian endometrioma with no suspected lesions in the appendix. She underwent laparoscopy and, after a systematic intraoperative evaluation, suspected involvement of the appendix was observed. The patient underwent ovarian cystectomy, excision of the pelvic endometriosis lesions, appendectomy, and anterior stapler discoid resection. Histopathological analysis of the appendix revealed endometriosis and a well-differentiated neuroendocrine carcinoma at the appendix tip.

DISCUSSION

Our patient's case emphasizes the need to approach these lesions carefully and strengthens the indication for appendectomy when the appendix is affected in the setting of endometriosis. Despite the more likely diagnosis of appendiceal endometriosis, neuroendocrine tumors cannot be ruled out by imaging examinations, and both conditions can occur in the same patient.

Current Status of Transvaginal Ultrasound Accuracy in the Diagnosis of Deep Infiltrating Endometriosis Before Surgery: A Systematic Review of the Literature

Endometriosis is a common gynecologic condition affecting as many as 1 per 10 women. Transvaginal ultrasound (TVUS) has become a frontline tool in the diagnosis of deep infiltrating endometriosis (DIE) before surgery. The primary aim of this review was to determine the accuracy of TVUS for DIE. The secondary aim was to determine accuracy specifically when a sonographer performed the TVUS examination. A systematic review was performed, searching literature by following a population, intervention, comparator, and outcome outline. MEDLINE, Embase, Emcare, and Google Scholar were searched in July 2018 and in November 2019. Including "sonographer" in the search terms yielded no results, so our terms were expanded. Two hundred and four articles were returned from the searches, and 35 were ultimately included in the final review. Analysis of the returned articles revealed the TVUS is a valuable diagnostic tool for DIE before surgery. Sensitivities ranged from 78.5% to 85.3%, specificities from 46.1% to 92.5%, and accuracies from 75.7% to 97%. Most authors reported site-specific sensitivities and specificities, which varied greatly between locations. Site-specific sensitivities ranged from 10% to 88.9% (uterosacral ligaments), 20% to 100% (bladder), 33.3% to 98.1% (rectosigmoid colon), and 31% to 98.7% (pouch of Douglas). Site-specific specificities ranged from 75% to 99.6% (uterosacral ligaments), 96.4% to 100% (bladder), 86% to 100% (rectosigmoid colon), and 90% to 100% (pouch of Douglas). Transvaginal ultrasound is an accurate tool in the diagnosis of DIE; however, limited data exist as to whether this technique is accurate when performed by sonographers. More evidence surrounding the reliability between operators is also needed.

Deep endometriosis: The place of laparoscopic shaving

Deep endometriosis (DE) is considered to be one of the most challenging conditions to manage, especially when it invades surrounding organs like the rectum. Surgical excision of deep rectovaginal endometriosis is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions, or if they evolve. Preoperative radiological examination should be extensive to determine the appropriate surgery: laparoscopic shaving, disc excision, or rectal resection. We demonstrated that in the hands of experienced surgeons, rectal shaving is possible for DE in more than 95% of cases, with low complication rates compared to rectal resection. Shaving and bowel resection are associated with comparable recurrence rates. As shaving is indicated whatever the size of deep lesions, surgeons should first consider rectal shaving to remove DE. Bowel resection should only be performed in case of major rectal stenosis (>80%), multiple and/or posterior rectal lesions and stenotic sigmoid colon lesions.

Comparison of routine pelvic US and MR imaging in patients with pathologically confirmed endometriosis

PURPOSE

To estimate the benefit of pelvic magnetic resonance (MR) imaging after routine pelvic ultrasound (US) in patients with pathologically or surgically proven endometriosis.

METHODS

Patients with surgically or pathologically proven endometriosis who had routine pelvic US followed by pelvic MR within 6 months prior to surgery were included. Patients were excluded if they had previously confirmed endometriosis, pregnancy, or surgery > 6 months after MR. The detection rate of endometriosis by pelvic US and MR was compared to the surgical/pathological reference standard.

RESULTS

83 female patients (mean age 40 ± 9) met inclusion criteria and had surgical/pathological confirmation of endometriosis. The mean time interval between pelvic US and MR was 33 ± 43 days, with 64 ± 69 days between MR examination and surgery. US detected endometriosis in 22% (18/83) of patients compared to 61% (51/83) for MR (p < 0.0001). 51% (33/65) of patients with a negative pelvic US exam had a positive MR. MR identified additional sites or sequela in the majority of patients with a positive US (14/18; 78%), including extraovarian locations [e.g., fallopian tubes 7/18 (39%), uterus 7/18 (39%), uterine ligaments 6/18 (33%), posterior cul de sac 5/18 (28%), pelvic side walls 5/18 (28%), abdominal wall 1/18 (6%)] and sequela [ovarian tethering 5/18 (28%), 6/18 (33%) bowel adhesive disease, posterior cul de sac obliteration 2/18 (11%), hydrosalpinx 2/18 (11%), and hydronephrosis 1/18 (6%)]. 3 T MR detected endometriosis in 33/46 (72%) patients compared to 18/37 (49%) for 1.5 T MR (p = 0.03).

CONCLUSION

Pelvic MR imaging had a higher detection rate of surgically/pathologically proven endometriosis and provides more information about disease location and sequela compared to routine pelvic US.

Sonographer-acquired ultrasound protocol for deep endometriosis

Endovaginal sonographic imaging has been shown to reliably identify pelvic endometriosis, but most United States imaging practices do not adequately assess locations and features of endometriosis beyond ovarian endometrioma. In this article, we propose a protocol for sonographer-acquired images and maneuvers to be interpreted subsequently by sonologists (radiologists or gynecologists). The purpose is to improve the sensitivity of endovaginal sonography for the detection of endometriosis in imaging practices that involve the non-physician sonographer as part of their workflow.

Ultrasound evaluation of deeply infiltrative endometriosis: technique and interpretation

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue located outside the uterus and frequently associated with chronic pelvic pain and infertility. It is a polymorphic disease that can be presented as superficial implants, endometriomas and deep lesions that infiltrate the peritoneal surface associated with fibrosis and inflammatory reaction. Diagnosis of deep endometriosis is difficult and delayed, frequently missed in a routine ultrasound. Transvaginal ultrasound is the first-line imaging modality to investigate endometriosis and when performed by an expert in female pelvic imaging can provide a reliable mapping of the affected sites. Bowel preparation can be used to improve the detection of bowel lesions as well as the other sites affected by eliminating artifacts. Surgery has been the mainstay to treat symptomatic endometriosis and preoperative imaging mapping is crucial for better results and to reduce residual disease. The goals of surgery include radical removal of all lesions and the restoration of normal pelvic anatomy. The author describes technical aspects and imaging interpretation of the transvaginal sonography to investigate deeply infiltrative endometriosis.

Endometriosis-associated pain scores and biomarkers in users of the etonogestrel-releasing subdermal implant or the 52-mg levonorgestrel-releasing intrauterine system for up to 24 months

Objectives: The aims of the study were to correlate endometriosis-associated pain, evaluated by visual analogue scale (VAS) scores, with serum levels of etonogestrel (ENG), levonorgestrel (LNG), CA-125 and soluble CD23 in users of the ENG implant or the 52-mg LNG-releasing intrauterine system (52 mg LNG-IUS) for up to 2 years after device placement.Methods: A randomised trial was conducted at the University of Campinas Medical School, Brazil. All participants (n = 103) had had endometriosis-associated chronic pelvic pain or dysmenorrhoea, or both, for more than 6 months. Participants were randomly assigned to use an ENG implant (experimental treatment) or a 52-mg LNG-IUS (active comparator). Follow-up was conducted 6 monthly for up to 24 months after device placement. Dysmenorrhoea and chronic pelvic pain were evaluated using a VAS and the scores were correlated with serum levels of ENG, LNG, CA-125 and soluble CD23.Results: Both progestin-only contraceptives significantly reduced VAS scores for dysmenorrhoea and chronic pelvic pain and reduced serum levels of soluble CD23 (p < 0.001). Serum levels of CA-125 decreased only in the ENG implant group after 24 months' use of the device (p < 0.001). No correlation was found between pain scores and ENG or LNG serum levels over time (p > 0.005).Conclusion: Both contraceptives improved dysmenorrhoea and chronic pelvic pain scores in women with endometriosis-associated pain and they reduced serum levels of soluble CD23; however, serum levels of CA-125 were reduced only in ENG implant users over the 24-month study period.

Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis

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.

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.

Preoperative Ultrasound Indications Determine Excision Technique for Bowel Surgery for Deep Infiltrating Endometriosis: A Single, High-Volume Center

STUDY OBJECTIVE

To identify bowel nodule features of deep infiltrating endometriosis (DIE) measured through preoperative ultrasound scanning that influence laparoscopic surgical strategy.

DESIGN

A retrospective study.

SETTING

Malzoni Clinic-Endoscopica Malzoni Department, Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy.

PATIENTS

Patients undergoing laparoscopic surgery between January 1, 2014, and December 31, 2018, for clinically suspected DIE with previous ultrasound evaluation ≤1 month before intervention.

INTERVENTION

Use of sonographic measurements to determine laparoscopic excision technique (segmental bowel resection, discoid resection, shaving) for DIE with bowel involvement.``` MEASUREMENTS AND MAIN RESULTS: Of 5051 DIE surgeries, 4983 were included; 1494 (29.9%) bowel resections (512 bowel segmental resections and 982 nodulectomies [967 shaving and 15 discoid resections]) were performed, accounting for 34.3% and 65.7% of all bowel procedures, respectively. Preoperative sonographic findings and surgical reports were collected. Sensitivity and specificity of preoperative ultrasound evaluation for all types of DIE lesions were calculated, and sonographic measurements of bowel nodules and different surgical techniques were compared. According to preoperative sonographic measurements, most nodules excised by segmental resection had a longitudinal diameter of 3 to 7 cm, none were <3 cm; all nodules excised by nodulectomy (shaving or discoid resection) had a longitudinal diameter <3 cm. Mean thickness (maximum depth of muscular layer infiltration) of identified bowel nodules estimated through ultrasound scanning was 13.4 mm ± 4.8 mm (mean ± standard deviation) and 5.8 mm ± 2.7 mm for lesions removed by segmental resection and nodulectomy, respectively, and there was a statistically significant difference between them (p <.05). Of the 512 segmental resected bowel nodules, 143 (28%) had a maximum depth ≥9 mm, 354 (69%) had 7 to 9 mm, and 15 (3%) had <7 mm (6 mm, with length >4 cm). All shaved nodules had thickness ≤7 mm. The 15 nodules excised by discoid resection (1.5% of nodulectomies) were <25 mm, but thickness ranged from 7 to 9 mm.

CONCLUSION

The need for segmental resection in DIE with bowel-infiltrating nodules depends on the degree of muscular layer infiltration and corresponding thickness (muscularis rule) in addition to nodule length and can be accurately identified by preoperative ultrasound evaluation.

Levator ani evaluation at transperineal elastography in women with deep infiltrating endometriosis postoperatively

OBJECTIVE

To explore whether operation can change the elasticity of levator ani in deep infiltrating endometriosis (DIE) with operation and pharmacotherapy using transperineal elastography.

METHODS

Total thirty-four patients who were diagnosed as DIE were included in the study. Transperineal elastography were performed in all cases preoperatively and postoperatively. The levator ani was evaluated by means of the scoring system and strain ratio (SR) values on maximal Valsalva and quiescent condition, respectively.

RESULTS

On quiescent condition, the preoperative mean elastography scores and SR of the levator ani were statistically significantly higher than the postoperative ones in both shaving technique group and segmental colorectal resection group. And on maximal Valsalva, the preoperative mean elastography scores and SR of the levator ani were statistically significantly lower than the postoperative ones in both groups. After surgery and 6 cycles of GnRHa therapy, the mean elastography score and SR of the levator ani were statistically significantly lower than before GnRHa therapy in shaving technique group on quiescent condition. And on maximal Valsalva, the mean elastography score and SR were statistically higher than before GnRHa therapy. However, in segmental colorectal resection group, the differences were not observed before and following 6 cycles of GnRHa therapy.

CONCLUSION

The elasticity of levator ani of DIE was changed by both shaving technique and segmental colorectal resection. And transperineal elastography could access the alterations.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Hormone treatment as first line therapy is safe and relieves pelvic pain in women with bowel endometriosis

OBJECTIVE

To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy.

METHODS

Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016.

RESULTS

Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001).

CONCLUSION

Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.

Structured Ultrasound and Magnetic Resonance Imaging Reports for Patients with Suspected Endometriosis: Guide for Imagers and Clinicians

In this article we propose a structured imaging report applied to ultrasound and magnetic resonance imaging in patients with suspected endometriosis.

Transvaginal sonography with vs without bowel preparation in diagnosis of rectosigmoid endometriosis: prospective study

OBJECTIVES

The primary aim of this study was to compare the diagnostic accuracy of transvaginal sonography (TVS) with vs without bowel preparation (BP) in detecting the presence of rectosigmoid endometriosis. Secondary objectives were to compare the diagnostic accuracy of the two techniques in estimating infiltration of the submucosa, length of the largest rectosigmoid nodules, distance of the nodules from the anal verge and presence of multifocal disease.

METHODS

This was a prospective study of patients with symptoms of pelvic pain for more than 6 months and/or suspicion of endometriosis referred to our institution between October 2016 and April 2018. Participants underwent a first TVS without BP followed by TVS with BP within a time interval of 1 week to 3 months. The examinations were performed independently and blindly by two sonographers. Only patients who underwent laparoscopy within the 6 months following the second ultrasound examination were included. Ultrasound results using the two techniques were compared with surgical and histological findings.

RESULTS

Of the 262 patients included in the study, 118 had rectosigmoid endometriosis confirmed at surgery. There was no significant difference in accuracy between TVS with and that without BP in diagnosing the presence of rectosigmoid endometriosis (93.5% vs 92.3%; P = 0.453). No significant difference was observed in accuracy between TVS with and that without BP in diagnosing submucosal infiltration (88.8% vs 84.6%; P = 0.238) and multifocal disease (97.2% vs 95.2%; P = 0.727) in patients diagnosed sonographically with rectosigmoid endometriosis. The accuracy of TVS with BP was similar to that of TVS without BP in estimating the maximum diameter of the largest nodule (P = 0.644) and the distance between the more caudal rectosigmoid nodule and the anal verge (P = 0.162).

CONCLUSION

BP does not improve the diagnostic performance of TVS in detecting rectosigmoid endometriosis and in assessing characteristics of endometriotic nodules. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.