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Montanari E, Bokor A, Szabó G, Kondo W, Trippia CH, Malzoni M, Di Giovanni A, Tinneberg HR, Oberstein A, Rocha RM, Leonardi M, Condous G, Alsalem H, Keckstein J, Hudelist G. Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:385-391. [PMID: 34919760 DOI: 10.1002/uog.24833] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To compare the preoperative detection of endometriosis using transvaginal sonography (TVS) supplemented by transabdominal sonography (TAS) with surgical assessment of disease, using the #Enzian classification for endometriosis. METHODS This was a prospective multicenter diagnostic accuracy study of women undergoing TVS/TAS and radical surgery for deep endometriosis (DE) at different tertiary referral centers. The localization and grade of severity of the endometriotic lesions and adhesions were described according to the criteria of the #Enzian classification, both at preoperative ultrasound examination and during surgery. According to the #Enzian classification, the small pelvis is divided into three compartments for DE: A (rectovaginal septum and vagina); B (uterosacral and cardinal ligaments, parametrium and pelvic sidewalls); and C (rectum). In addition, further locations (F) are classified as adenomyosis (FA), urinary bladder involvement (FB) and ureteric involvement with signs of obstruction (FU). Other intestinal locations (FI) and other extragenital locations (FO) are also included. Ovarian endometriosis and adhesions at the level of the tubo-ovarian unit are listed as O and T, respectively. The #Enzian grade of severity (Grade 1-3) was determined for #Enzian compartments O, T, A, B and C based on the size of the lesion or the severity of the adhesions. Concordance between preoperative assessment using TVS/TAS and evaluation at surgery was assessed. The sensitivity, specificity, positive and negative predictive values and accuracy of TVS/TAS in the detection of endometriotic lesions/adhesions in the different #Enzian compartments were calculated. RESULTS In total, 745 women were included in the analysis. Preoperative TVS/TAS and surgical findings showed a concordance rate ranging between 86% and 99% for the presence or absence of endometriotic lesions/adhesions, depending on the evaluated #Enzian compartment. The concordance rate between TVS and surgery ranged between 71% and 92% for different severity grades, in #Enzian compartments O, T, A, B and C. Determining the presence or absence of adhesions at the level of the tubo-ovarian unit and classifying them accurately as Grade 1, 2 or 3 on TVS was more difficult than determining the presence and severity of endometriotic lesions in #Enzian compartments O, A, B and C. The sensitivity of TVS/TAS for the detection of endometriotic lesions ranged from 50% (#Enzian compartment FI) to 95% (#Enzian compartment A), specificity from 86% (#Enzian compartment Tleft ) to 99% (#Enzian compartment FI) and 100% (#Enzian compartments FB, FU and FO), positive predictive value from 90% (#Enzian compartment Tright ) to 100% (#Enzian compartment FO), negative predictive value from 74% (#Enzian compartment Bleft ) to 99% (#Enzian compartments FB and FU) and accuracy from 88% (#Enzian compartment Bright ) to 99% (#Enzian compartment FB). CONCLUSIONS The localization and severity of endometriotic lesions/adhesions, as described and classified according to the #Enzian classification, can be diagnosed accurately and non-invasively using TVS/TAS. The #Enzian classification provides a uniform classification system for describing endometriotic lesions, which can be used both at TVS/TAS and during surgical evaluation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Montanari
- Department of Gynecology, Center for Endometriosis, Hospital St John of God, Vienna, Austria
| | - A Bokor
- Department of Obstetrics and Gynecology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - G Szabó
- Department of Obstetrics and Gynecology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - W Kondo
- Department of Gynecology and Minimally Invasive Unit, Vita Batel Hospital, Curitiba, Brazil
| | - C H Trippia
- Department of Radiology, Roentgen Diagnóstico Institute, Curitiba, Brazil
| | - M Malzoni
- Endoscopica Malzoni, Centre for Advanced Pelvic Surgery, Avellino, Italy
| | - A Di Giovanni
- Endoscopica Malzoni, Centre for Advanced Pelvic Surgery, Avellino, Italy
| | - H R Tinneberg
- Department of Obstetrics and Gynecology, Nordwest Hospital, Frankfurt, Germany
| | - A Oberstein
- Department of Obstetrics and Gynecology, Nordwest Hospital, Frankfurt, Germany
| | - R M Rocha
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopy Surgery Unit, Nepean Hospital, Kingswood, NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - M Leonardi
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopy Surgery Unit, Nepean Hospital, Kingswood, NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - H Alsalem
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - J Keckstein
- Stiftung Endometrioseforschung (SEF), Westerstede, Germany
| | - G Hudelist
- Department of Gynecology, Center for Endometriosis, Hospital St John of God, Vienna, Austria
- Stiftung Endometrioseforschung (SEF), Westerstede, Germany
- Rudolfinerhaus Private Clinic, Vienna, Austria
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Serial assessment of inflammatory parameters for prediction of septic complications following surgery for colorectal endometriosis : A descriptive, retrospective study. Wien Klin Wochenschr 2021; 134:118-124. [PMID: 34338850 PMCID: PMC8857128 DOI: 10.1007/s00508-021-01916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/30/2021] [Indexed: 12/03/2022]
Abstract
Purpose To assess whether C‑reactive protein (CRP), white blood cell count (WBC) and body temperature changes are suitable parameters for the early detection of septic complications following resection of colorectal deep endometriosis (DE). Methods Retrospective data analysis of CRP, WBC and body temperature courses following colorectal surgery for DE at a tertiary referral center for endometriosis. Results Out of 183 surgeries performed, 10 major surgical complications were observed, including 4 anastomotic leakages (AL 2%) and 2 rectovaginal fistulae (RVF 1%). In the presence of a lower gastrointestinal tract (GIT)-related septic complication or abdominal wall abscess, serum CRP levels were increased starting at postoperative day 2–3. A cut-off value of 10 mg/dl on day 4 for prediction of early septic complications could be verified (area under the curve 0.94, obtained by receiver operating characteristics analysis, sensitivity 88%, specificity 90%, positive predictive value 32%, negative predictive value 99%). Additionally, most patients with early septic complications exhibited increased WBC levels starting mainly from day 3–4; however, increased inflammatory parameters could not be observed in one patient with an RVF. Body temperature did not prove useful for early discrimination between uncomplicated cases and those with early septic complications. Conclusion Relevant elevations of serum CRP and WBC levels were demonstrated in patients with early septic complications following surgery for colorectal DE starting at postoperative day 2–4. The cut-off value of 10 mg/dl for CRP levels may serve as an early predictor for lower GIT-related septic complications but should be used with caution in women with suspected RVF development. Supplementary Information The online version of this article (10.1007/s00508-021-01916-w) contains supplementary material, which is available to authorized users.
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Comparison between Sonography-based and Surgical Extent of Deep Endometriosis Using the Enzian Classification - A Prospective Diagnostic Accuracy Study. J Minim Invasive Gynecol 2021; 28:1643-1649.e1. [PMID: 33582378 DOI: 10.1016/j.jmig.2021.02.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/05/2021] [Accepted: 02/10/2021] [Indexed: 01/13/2023]
Abstract
STUDY OBJECTIVE To compare a preoperative evaluation of deep endometriosis (DE) by transvaginal sonography (TVS) according to the Enzian classification with the intraoperatively assessed extent of DE using the Enzian system. DESIGN Prospective diagnostic accuracy study. SETTING Tertiary referral center for endometriosis. PATIENTS Women undergoing TVS and surgery for DE between 2017 and 2019 (N = 195). INTERVENTIONS Evaluation of DE lesion sizes according to the Enzian classification as evaluated by preoperative TVS compared with surgical findings. MEASUREMENTS AND MAIN RESULTS The rate of exact concordances between preoperative TVS-based predictions of DE lesion sizes and intraoperatively assessed lesion sizes according to the Enzian classification varied depending on anatomic localizations, that is, Enzian compartments, and evaluated lesion size. The highest rate of exact concordances was found in Enzian compartment C (rectosigmoid) in which 86% of all TVS C3 lesions were confirmed as such at surgery. Enzian compartment A (vagina, rectovaginal septum) showed similar results. The rates of exact concordances were slightly lower in Enzian compartment B (uterosacral ligaments, parametria), with confirmation at surgery of 71% of TVS B2 lesions. In most cases of discordant findings, an underestimation of the lesion size by 1 severity grade was observed compared with the intraoperative findings. In Enzian compartment FB (urinary bladder), 91% of the lesions seen at TVS and 98% of cases without any lesion at TVS were confirmed surgically. TVS could detect DE preoperatively in compartments A, B, C, and FB with an overall sensitivity of 84%, 91%, 92%, and 88%, respectively, and a specificity of 85%, 73%, 95%, and 99%, respectively. CONCLUSION TVS provides a valuable preoperative estimation of DE localization and lesion size using the Enzian classification, especially for Enzian compartments A, C, and FB. For Enzian compartment B, the exact assessment of the lesion size using the Enzian system seems to be less precise than for the other compartments.
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Montanari E, Dauser B, Keckstein J, Kirchner E, Nemeth Z, Hudelist G. Association between disease extent and pain symptoms in patients with deep infiltrating endometriosis. Reprod Biomed Online 2019; 39:845-851. [PMID: 31378689 DOI: 10.1016/j.rbmo.2019.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/08/2019] [Accepted: 06/14/2019] [Indexed: 11/18/2022]
Abstract
RESEARCH QUESTION The study aimed to assess the associations between pre-operative symptoms in patients with deep infiltrating endometriosis (DIE) and intraoperatively determined extent of disease as described by the revised ENZIAN score. DESIGN This was a retrospective data analysis of women who underwent surgery for DIE between 2014 and 2018 at the Department of Gynecology, Hospital St. John of God, Vienna (a tertiary referral centre for endometriosis). RESULTS Data from 245 women were analysed. Statistically significant associations were found between involvement of ENZIAN compartment B (uterosacral ligaments, parametrium) and presence of dyspareunia (P = 0.002), ENZIAN compartment C (rectum, sigmoid colon) and dyschezia (P < 0.001), and ENZIAN compartment FB (urinary bladder) and dysuria (P < 0.001, Fisher's exact test). Statistically significant correlations were also detected between symptom severity of dyschezia and lesion size in ENZIAN compartment C (rs = 0.334, P < 0.001), and severity of dyspareunia and lesion size in ENZIAN compartment B (rs = 0.127, P = 0.046). Severity of dysmenorrhoea was correlated with lesion size in ENZIAN compartment A (rs = 0.244, P < 0.001) and was associated with the presence of adenomyosis (compartment FA; P = 0.005, Mann-Whitney U-test). Additionally, the number of affected compartments (A, B, C and FA) correlated with the severity of dysmenorrhoea (rs = 0.256, P < 0.001) and dyschezia (rs = 0.161, P = 0.012). CONCLUSION In contrast to previous studies evaluating disease extent based on the revised American Society for Reproductive Medicine (rASRM) score, disease localization and extent as described by the revised ENZIAN score was associated and correlated with the presence and severity of different pre-operative symptoms. These explorative findings suggest that it may be important to evaluate the extent of DIE using the revised ENZIAN score in addition to the rASRM score.
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Affiliation(s)
- Eliana Montanari
- Department of Gynecology, Hospital St. John of God, Vienna, Austria; Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Bernhard Dauser
- Department of General Surgery, Hospital St. John of God, Vienna, Austria
| | - Joerg Keckstein
- Stiftung Endometrioseforschung (SEF), Westerstede, Germany; Gynecological Clinic Drs Keckstein, Villach, Austria
| | | | - Zoltan Nemeth
- Department of Gynecology, Hospital St. John of God, Vienna, Austria
| | - Gernot Hudelist
- Department of Gynecology, Hospital St. John of God, Vienna, Austria; Stiftung Endometrioseforschung (SEF), Westerstede, Germany.
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Surgical laparoscopic treatment of bowel endometriosis with transvaginal resection of the rectum using ultrasonically activated shears: a retrospective cohort study with description of technique. Arch Gynecol Obstet 2018; 297:985-988. [DOI: 10.1007/s00404-018-4692-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 01/29/2018] [Indexed: 10/18/2022]
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Abstract
Endometriosis is a common condition with significant morbidity, including pain and subfertility, which is often subject to a delay in diagnosis. Ultrasound has been successfully utilized, mostly outside North America, to preoperatively stage deep endometriosis, but in these international settings, imaging is typically performed solely by expert radiologists and gynecologists. We outline a method for detailed sonographic survey of the lower abdomen and pelvis to ensure optimum detection and communication of disease extent that is geared to radiologists practicing ultrasound in the United States, with the use of diagnostic medical sonographers.
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Cimsit C, Yoldemir T, Guclu M, Akpinar IN. Susceptibility-weighted magnetic resonance imaging for the evaluation of deep infiltrating endometriosis: preliminary results. Acta Radiol 2016; 57:878-85. [PMID: 26315838 DOI: 10.1177/0284185115602147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/29/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Knowledge of the precise sites of deep infiltrating endometriosis (DIE) lesions is essential for preoperative workup and treatment. Susceptibility-weighted imaging (SWI) has high sensitivity for blood products and have recently been applied in abdominal imaging. PURPOSE To determine the value of SWI in the diagnosis of DIE. MATERIAL AND METHODS Forty-three clinically suspected DIE patients with sonographically diagnosed ovarian endometriomas who had tenderness or palpable nodule(s) on rectovaginal examination were referred to pelvic magnetic resonance imaging (MRI) including SWI. Two patients were excluded from the study because of low quality of SWI series. Twenty-eight patients who were offered laparoscopic endometriosis surgery (LES) preferred medical treatment over surgical approach. Thirteen out of 41 participants had LES. Lesions were evaluated for their locations, signal intensities on T1-weighted (T1W) and T2-weighted (T2W) images, and presence of signal voids on SWI using 3T MRI and correlated with LES findings. RESULTS A total of 18 endometriosis foci were laparoscopically removed from 13 patients. DIE lesions removed at laparoscopy were located at the uterosacral ligament (9/18), rectovaginal region (4/18), retrocervical region (2/18), and fallopian tubes (3/18). Eleven out of 18 (61%) DIE foci were detected by their high-signal intensities on T1W images whereas 16 out of 18 (89%) DIE foci were detected by signal voids on SWI. CONCLUSION SWI imaging with its high sensitivity to blood products, contributes to the diagnosis of DIE by depicting different phases of hemorrhage not seen by conventional MRI sequences.
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Affiliation(s)
- Canan Cimsit
- Marmara University Training and Research Hospital, Department of Radiology, Istanbul, Turkey
| | - Tevfik Yoldemir
- Marmara University Training and Research Hospital, Department of Obstetrics and Gynaecology, Istanbul, TURKEY
| | - Mehmet Guclu
- Marmara University Training and Research Hospital, Department of Obstetrics and Gynaecology, Istanbul, TURKEY
| | - Ihsan Nuri Akpinar
- Marmara University Training and Research Hospital, Department of Radiology, Istanbul, Turkey
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Bokor A, Brubel R, Lukovich P, Rigó J. [Experience with multidisciplinary laparoscopic surgery in patients with deep infiltrating colorectal endometriosis]. Orv Hetil 2014; 155:182-6. [PMID: 24463164 DOI: 10.1556/oh.2014.29809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep infiltrating endometriosis is a particular form of endometriosis that penetrates the peritoneal surface or it reaches the subserosal neurovascular plexus. AIM The aim of the authors was to analyze the results of segmental colorectal resections performed for deep infiltrating endometriosis. METHOD Between 2009 and 2012, 50 patients underwent segmental rectum or/and sigmoid resection for endometriosis. RESULTS 21 patients had ultralow rectal resection and 29 patients had low colorectal anastomosis or anterior resection. Concomitant intervention in other organs was required in all cases, including gynecologic procedures (n = 50), additional gynecologic (n = 47), vesical (n = 9) and ureteral (n = 18) resections. The mean number of endometriosis lesions was 2.4±1.8 per patient. In all patients fertility was preserved. Severe surgical complications (Clavien-Dindo stage III or more severe) occurred in 3 patients (6%). CONCLUSIONS The results confirm that segmental bowel resection is an efficient and safe method for the treatment of deep infiltrating colorectal endometriosis. Orv. Hetil., 2014, 155(5), 182-186.
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Affiliation(s)
- Attila Bokor
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Szülészeti és Nőgyógyászati Klinika Budapest Baross u. 27. 1085
| | - Réka Brubel
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Szülészeti és Nőgyógyászati Klinika Budapest Baross u. 27. 1085
| | - Péter Lukovich
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest
| | - János Rigó
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Szülészeti és Nőgyógyászati Klinika Budapest Baross u. 27. 1085
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Fiaschetti V, Crusco S, Meschini A, Cama V, Di Vito L, Marziali M, Piccione E, Calabria F, Simonetti G. Deeply infiltrating endometriosis: Evaluation of retro-cervical space on MRI after vaginal opacification. Eur J Radiol 2012; 81:3638-45. [DOI: 10.1016/j.ejrad.2011.06.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 06/27/2011] [Accepted: 06/29/2011] [Indexed: 10/17/2022]
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Abstract
PURPOSE OF REVIEW Rectal endometriosis is a very indolent disease whose treatment has been debated by a range of competing schools. Meanwhile, not all audiences in the scientific community are entirely familiar with the full aspects of the disease. Hence, the purpose of this review is to outline the basic as well as the recent literature pertaining to the disease, thus offering a broader view to the interested reader. RECENT FINDINGS Laparoscopic shaving or disc excision for rectal endometriotic nodules may be simple, safe options of controlling the disease. On the contrary, laparoscopic rectal resections, originally reserved for more extensive disease, are now more skillfully mastered by surgeons and gynecologists. Meta-analyses, retrospective, and prospective studies are being published frequently supporting one form of therapy at a time and discrediting another at other times. SUMMARY Laparoscopic shaving or disc excisions for rectal endometriotic foci or rectal resections are feasible and efficient methods for treating rectal endometriosis. More complex surgery to the bowel means more risk for complications. With the rising learning curve of the operators, laparoscopic rectal resections have become a safe option that should be offered to patients. The patient's preference to a particular treatment option should be central to the type of surgery to be elected.
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Jelenc F, Ribič-Pucelj M, Juvan R, Kobal B, Sinkovec J, Salamun V. Laparoscopic rectal resection of deep infiltrating endometriosis. J Laparoendosc Adv Surg Tech A 2011; 22:66-9. [PMID: 22166117 DOI: 10.1089/lap.2011.0307] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Deep infiltrating endometriosis with colorectal involvement is a complex disorder, often requiring segmental bowel resection. Complete removal of all visible lesions is considered the adequate treatment of infiltrating endometriosis in order to reduce recurrence. In this article, we describe our experience with laparoscopic management of deep infiltrating endometriosis with involvement of the rectum. METHODS A retrospective analysis of data from patients with deep infiltrating endometriosis with rectal involvement who underwent a laparoscopic surgery in the years 2002-2009 at the Department of Obstetrics and Gynecology at our institution was done. RESULTS Between 2002 and 2009, a laparoscopic partial rectal resection was performed in 52 patients, and laparoscopic disk resection was performed in 4 cases with deep infiltrating endometriosis. The mean age of patients was 34.4 years (range, 22-62 years). Preoperative symptoms included dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. The laparoscopic procedure was converted to formal laparotomy in 3 patients (5.4%). The mean duration of surgery was 145 minutes. Postoperative complications included 3 cases of anastomotic leakage with rectovaginal fistula in two cases and intraabdominal bleeding in 1 case. The mean hospital stay was 7 days. Postoperatively, nine patients had a normal delivery, two of them after in vitro fertilization treatment. CONCLUSION Laparoscopic rectal resection for deep infiltrating endometriosis is a relatively safe procedure, when performed by a surgeon and a gynecologist with sufficient experience in laparoscopic colorectal surgery.
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Affiliation(s)
- Franc Jelenc
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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Is Pouch of Douglas Obliteration a Marker of Bowel Endometriosis? J Minim Invasive Gynecol 2011; 18:333-7. [DOI: 10.1016/j.jmig.2011.01.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 01/11/2011] [Accepted: 01/06/2011] [Indexed: 11/21/2022]
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Yoon JH, Choi D, Jang KT, Kim CK, Kim H, Lee SJ, Chun HK, Lee WY, Yun SH. Deep rectosigmoid endometriosis: "mushroom cap" sign on T2-weighted MR imaging. ACTA ACUST UNITED AC 2011; 35:726-31. [PMID: 20820774 DOI: 10.1007/s00261-010-9643-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the "mushroom cap" sign on T2-weighted MR imaging in patients with submucosal tumors in the rectosigmoid colon. METHODS From January 2001 to August 2009, 12 patients with four different diseases presenting or mimicking submucosal tumors in the rectosigmoid colon underwent colonic resection. All patients with deep endometriosis (n = 6), gastrointestinal stromal tumor (n = 4), metastasis from ovary cancer (n = 1), and carcinoid tumor (n = 1) had either an MRI of the rectum or pelvis before surgery. We evaluated the MRI findings and compared them with the macroscopic and microscopic observations in the resected specimens. RESULTS In all six cases of deep endometriosis, a characteristic "mushroom cap" shaped appearance was found on T2-weighted MR imaging. Heterogeneous low signal intensity of the hypertrophic muscularis propria, covered with high signal intensity of the mucosa and submucosa on T2-weighted MR images, looked like a "mushroom cap" with the pattern of intraluminal endophytic growth. In histological findings, deep endometriosis involved the submucosa (n = 4) or mucosa (n = 2). The "mushroom cap" sign was not present in any of the six other tumors. CONCLUSION The "mushroom cap" sign on T2-weighted MR imaging may be a characteristic sign for diagnosing deep rectosigmoid endometriosis.
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Affiliation(s)
- Jung Hwan Yoon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-Ku, Seoul, Korea
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Marcal L, Nothaft MA, Coelho F, Choi H. Deep pelvic endometriosis: MR imaging. ABDOMINAL IMAGING 2010; 35:708-15. [PMID: 20390267 DOI: 10.1007/s00261-010-9611-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Leonardo Marcal
- Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, USA.
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Landi S, Mereu L, Indraccolo U, Favero R, Fiaccavento A, Zaccoletti R, Clarizia R, Barbieri F. Laparoscopic excision of endometriosis may require unilateral parametrectomy. JSLS 2010; 13:496-503. [PMID: 20202390 PMCID: PMC3030782 DOI: 10.4293/108680809x12589998404047] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE We investigated the effects of laparoscopic excision of endometriosis with unilateral parametrectomy on bladder, rectal, and sexual function as well as patient satisfaction. METHODS Women who underwent this procedure between February 1, 2006 and November 15, 2007 were enrolled. Patient characteristics, pre- and postoperative findings, and follow-up data were retrospectively collected from a computerized database. RESULTS Twelve patients were enrolled in the study. All of the symptoms except dysuria improved after surgery, worsening long after the operation. It seems that all parameters including sexuality, micturition, and defecation are equally important in regards to the final judgement of satisfaction, with a trend towards amelioration long after the operation. CONCLUSIONS Unilateral parametrectomy may offer successful results in terms of patient satisfaction despite some impairment in bladder, bowel, and sexual function. The risk of permanent functional impairment is high; therefore, surgeons need to maintain the integrity of the contralateral nerve pathway. This is highly important, because pain relief seems to be partially involved in the final judgement of postoperation satisfaction.
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Affiliation(s)
- S Landi
- Department of Obstetrics and Gynecology, Ospedale Sacro Cuore, Verona, Italy
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Kamergorodsky G, Ribeiro PAA, Galvão MAL, Abrão MS, Donadio N, de Barros Moreira Lemos NL, Aoki T. Histologic classification of specimens from women affected by superficial endometriosis, deeply infiltrating endometriosis, and ovarian endometriomas. Fertil Steril 2009; 92:2074-7. [DOI: 10.1016/j.fertnstert.2009.05.086] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 05/13/2009] [Accepted: 05/27/2009] [Indexed: 11/30/2022]
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Severe endometriosis: laparoscopic rectum resection. Arch Gynecol Obstet 2009; 281:657-62. [DOI: 10.1007/s00404-009-1164-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 06/14/2009] [Indexed: 10/20/2022]
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De Nardi P, Osman N, Ferrari S, Carlucci M, Persico P, Staudacher C. Laparoscopic treatment of deep pelvic endometriosis with rectal involvement. Dis Colon Rectum 2009; 52:419-24. [PMID: 19333041 DOI: 10.1007/dcr.0b013e318197d716] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Our study aimed to evaluate the feasibility and outcome of laparoscopic excision of deep pelvic endometriosis with extensive rectal involvement causing severe symptoms. METHODS Ten patients, mean age 32 years (range, 27-43), with deep pelvic endometriosis and rectal wall involvement, requiring surgical resection, were studied since January 2004. Prior to surgery and 6 months postsurgery, patients completed a 100-point rank questionnaire on intensity of intestinal and extraintestinal symptoms. A laparoscopic approach was performed by a team of a gynecologist and colorectal surgeons. RESULTS At surgery, complete excision of infiltrating endometriosis was achieved, with 7 low rectal resections, 2 rectosigmoid resections, and 1 proctectomy with coloanal anastomosis. Additional procedures were: ureter resections (n = 2) with one reimplantation in the bladder, left ovariectomies (n = 2), ovarian endometrioma resections (n = 4), and laser ablation of superficial peritoneal lesions (n = 4). In four cases, a laparotomic conversion was needed. Mean follow-up was 27.6 months (range, 18-37). Neither intraoperative nor postoperative serious complications were observed. All the patients experienced significant improvement of intestinal and extraintestinal symptoms. CONCLUSIONS Laparoscopic resection of deep pelvic endometriosis with rectal involvement can be successful in improving digestive and gynecologic symptoms; however, this approach is challenging with a high rate of laparotomic conversion.
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Affiliation(s)
- Paola De Nardi
- Department of Surgery, Scientific Institute S. Raffaele Hospital, Vita-Salute University San Raffaele, Milan, Italy.
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Caractéristiques IRM de l’endométriose profonde : corrélation aux résultats cœlioscopiques. ACTA ACUST UNITED AC 2008; 89:1745-54. [DOI: 10.1016/s0221-0363(08)74479-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Nerve fibers in uterosacral ligaments of women with deep infiltrating endometriosis. J Reprod Immunol 2008; 79:93-9. [DOI: 10.1016/j.jri.2008.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 07/08/2008] [Accepted: 08/07/2008] [Indexed: 11/23/2022]
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Razzi S, Luisi S, Calonaci F, Altomare A, Bocchi C, Petraglia F. Efficacy of vaginal danazol treatment in women with recurrent deeply infiltrating endometriosis. Fertil Steril 2007; 88:789-94. [PMID: 17544421 DOI: 10.1016/j.fertnstert.2006.12.077] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 12/21/2006] [Accepted: 12/28/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe a safe long-term medical treatment for deeply infiltrating endometriosis, a critical condition characterized by multiple painful symptoms and a high recurrence rate after surgical treatment. DESIGN Prospective study. SETTING University of Siena. PATIENT(S) Twenty-one women with deeply infiltrating endometriosis. INTERVENTION(S) In a nonrandomized prospective study a low dose of vaginal danazol (200 mg/d) was self-administered for 12 months. After a previous laparoscopic surgery, these patients had reported recurrent severe dyspareunia, dysmenorrhea, and pelvic pain (in five cases also painful defecation). MAIN OUTCOME MEASURE(S) Before and every 3 months during the treatment a visual analogue pain scale was used. Transvaginal and transrectal ultrasound examinations were performed before and after 6 and 12 months of treatment. Adverse effects were registered, and serum concentration of cholesterol, triglycerides, aspartate aminotransferase, alanine aminotransferase, glycemia, protein S, protein C, antithrombin III, and homocysteine was evaluated before and after 12 months. RESULT(S) Dysmenorrhea, dyspareunia, and pelvic pain significantly decreased within 3 months and disappeared after 6 months of treatment, with a persistent effect during the 12 months of treatment. A relief of painful defecation was also shown. Ultrasound examination showed a reduction of the nodularity in the rectovaginal septum within 6 months. The medical treatment did not affect metabolic or thrombophilic parameters; few local vaginal adverse effects were reported. CONCLUSION(S) Vaginal danazol resulted in effective medical treatment for the various painful symptoms in women with recurrent deeply infiltrating endometriosis, and because of the lack of significant adverse effects it may be proposed as an alternative to repeated surgery.
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Affiliation(s)
- Sandro Razzi
- Division of Obstetrics and Gynecology, Department of Pediatrics, Gynecology and Reproductive Medicine, University of Siena, Siena, Italy
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Kanthimathinathan V, Elakkary E, Bleibel W, Kuwajerwala N, Conjeevaram S, Tootla F. Endometrioma of the large bowel. Dig Dis Sci 2007; 52:767-9. [PMID: 17268828 DOI: 10.1007/s10620-006-9623-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 09/24/2006] [Indexed: 12/09/2022]
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Del Frate C, Girometti R, Pittino M, Del Frate G, Bazzocchi M, Zuiani C. Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation. Radiographics 2006; 26:1705-18. [PMID: 17102045 DOI: 10.1148/rg.266065048] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Deep pelvic endometriosis is defined as subperitoneal infiltration of endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina, or bladder. It is responsible for severe pelvic pain. Accurate preoperative assessment of disease extension is required for planning complete surgical excision, but such assessment is difficult with physical examination. Various sonographic approaches (transvaginal, transrectal, endoscopic transrectal) have been used for this purpose but do not allow panoramic evaluation. Furthermore, exploratory laparoscopy has limitations in demonstrating deep endometriotic lesions hidden by adhesions or located in the subperitoneal space. Despite some limitations, magnetic resonance (MR) imaging is able to directly demonstrate deep pelvic endometriosis. The MR imaging features depend on the type of lesions: infiltrating small implants, solid deep lesions mainly located in the posterior cul-de-sac and involving the uterosacral ligaments and torus uterinus, or visceral endometriosis involving the bladder and rectal wall. Solid deep lesions have low to intermediate signal intensity with punctate regions of high signal intensity on T1-weighted images, show uniform low signal intensity on T2-weighted images, and can demonstrate enhancement on contrast-enhanced images. MR imaging is a useful adjunct to physical examination and transvaginal or transrectal sonography in evaluation of patients with deep infiltrating endometriosis.
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Affiliation(s)
- Chiara Del Frate
- Department of Radiology, University of Udine, Via Colugna 50, 33100 Udine, Italy.
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Bahr A, de Parades V, Gadonneix P, Etienney I, Salet-Lizée D, Villet R, Atienza P. Endorectal ultrasonography in predicting rectal wall infiltration in patients with deep pelvic endometriosis: a modern tool for an ancient disease. Dis Colon Rectum 2006; 49:869-75. [PMID: 16583293 DOI: 10.1007/s10350-006-0501-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study evaluated the validity of endorectal ultrasonography in predicting rectal infiltration in patients with deep pelvic endometriosis. METHODS Patients were recruited consecutively in the Department of Surgical Gynecology of Diaconesses Hospital from April 1996 to July 2003. Inclusion criteria were the suspicion of deep pelvic endometriosis on the basis of outpatient history and/or clinical symptoms with a mass palpable on bimanual examination that might infiltrate the rectal wall. There were no exclusion criteria. Endorectal ultrasonography was performed by the same investigator with a 7.5-MHz to 10-MHz rigid probe, producing a 360 degrees view of the rectal wall and adjacent areas. We used surgical and histopathologic findings as the "gold standard" to evaluate the validity of endorectal ultrasonography. RESULTS This study was based on 37 patients (mean age, 35.8 (range, 26-46) years) who underwent surgery. The time between endorectal ultrasonography and surgery ranged from 4 to 529 (mean, 88.7) days. Eight patients had endometriosis nodules penetrating the rectal wall. Endorectal ultrasonography showed sensitivity, specificity, a positive predictive value, and a negative predictive value of 87.5, 97, 87.5, and 97 percent, respectively, in the diagnosis of infiltration of the rectal wall by endometriosis. CONCLUSIONS Endorectal ultrasonography is a reliable technique for visualizing rectal infiltration in patients with deep pelvic endometriosis. It should be more widely used by gynecologists because knowing about rectal infiltration before surgery is fundamental to defining the best possible surgical approach.
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Affiliation(s)
- Abbas Bahr
- Proctologie Médico-Interventionnelle, Groupe Hospitalier Diaconesses--Croix Saint Simon, Paris, France
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Bazot M, Nassar J, Daraï E, Thomassin I, Cortez A, Buy JN, Uzan S, Marsault C. Valeurs diagnostiques de l’échographie et de l’IRM pour l’évaluation de l’endométriose pelvienne profonde. ACTA ACUST UNITED AC 2005; 86:461-7. [PMID: 16114201 DOI: 10.1016/s0221-0363(05)81390-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Deep pelvic endometriosis may involve the uterosacral ligaments, cul-de-sac of Douglas, vagina, rectum, and occasionally the bladder. Evaluation by physical examination is difficult, and imaging techniques are needed to evaluate the location and extent of endometriosis. In this review, we review the transvaginal and transrectal sonographic and MR imaging features suggestive of deep pelvic endometriosis and their diagnostic value.
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Affiliation(s)
- M Bazot
- Service de Radiologie, Hôpital Tenon, 4 rue de la Chine, 75020 Paris.
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Bazot M, Daraï E. Sonography and MR imaging for the assessment of deep pelvic endometriosis. J Minim Invasive Gynecol 2005; 12:178-85; quiz 177, 186. [PMID: 15904628 DOI: 10.1016/j.jmig.2005.01.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2004] [Accepted: 10/10/2004] [Indexed: 10/25/2022]
Abstract
Deep pelvic endometriosis may involve the uterosacral ligaments, the pouch of Douglas, the vagina, the rectum, and occasionally the bladder. Assessment by physical examination is difficult, and imaging techniques are needed to evaluate the location and extent of endometriosis. In this review, we describe transvaginal and rectal endoscopic sonographic and magnetic resonance imaging features suggestive of deep pelvic endometriosis and their diagnostic performance.
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Affiliation(s)
- Marc Bazot
- Department of Radiology, Hôpital Tenon, Paris, France.
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Abstract
Deep endometriosis is essentially characterized by the presence of a rectovaginal or retrocervical nodule, which is a circumscribed, nodular aggregate of smooth muscle, endometrial glands, and, usually, endometrial stroma. The authors suggest that the retroperitoneal space should definitely be considered as the origin of this retroperitoneal adenomyotic disease. This article reviews the classification, the diagnosis, and the surgical treatment of deep endometriosis (adenomyotic disease).
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Affiliation(s)
- Jacques Donnez
- Department of Gynecology, Catholic University of Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, Brussels 1200, Belgium.
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28
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Bazot M, Thomassin I, Hourani R, Cortez A, Darai E. Diagnostic accuracy of transvaginal sonography for deep pelvic endometriosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 24:180-185. [PMID: 15287057 DOI: 10.1002/uog.1108] [Citation(s) in RCA: 218] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To determine the accuracy of transvaginal sonography (TVS) for the diagnosis of deep pelvic endometriosis. METHODS In a prospective study, 142 women with clinical signs of endometriosis underwent TVS followed by surgical and histopathological investigations. The presence and extent of endometriosis involving the uterosacral ligaments, vagina, rectovaginal septum, intestines, bladder and ovaries shown by TVS were compared with surgical and histological findings. The sensitivity, specificity, predictive values and accuracy of TVS for predicting deep pelvic endometriosis were assessed. RESULTS Ovarian and deep pelvic endometriosis were found by surgery and histology in respectively 83 (58.5%) and 79 (55.6%) of the 142 patients. The sensitivity, specificity, and positive and negative predictive values of TVS for the diagnosis of deep pelvic endometriosis were 78.5%, 95.2%, 95.4% and 77.9%, respectively. The sensitivity and specificity of TVS for endometriotic involvement of the uterosacral ligaments, vagina, rectovaginal septum and intestines were 70.6% and 95.9%, 29.4% and 100%, 28.6% and 99.3%, and 87.2% and 96.8%, respectively. The sensitivity and specificity of TVS for bladder involvement were 71.4% and 100%, respectively. CONCLUSION TVS accurately diagnoses intestinal and bladder endometriosis, but is less accurate for uterosacral, vaginal and rectovaginal septum involvement.
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Affiliation(s)
- M Bazot
- Department of Radiology, Hôpital Tenon, Paris, France.
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Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN. Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology 2004; 232:379-89. [PMID: 15205479 DOI: 10.1148/radiol.2322030762] [Citation(s) in RCA: 369] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To prospectively evaluate the accuracy of magnetic resonance (MR) imaging for the preoperative diagnosis of deep pelvic endometriosis and extension of the disease. MATERIALS AND METHODS One hundred ninety-five patients (mean age, 34.2 years; range, 20-71 years) who were suspected of having pelvic endometriosis were recruited at two institutions. Two experienced radiologists evaluated the MR images independently. Deep pelvic endometriosis was defined as implants or tissue masses that appeared as hypointense areas and/or hyperintense foci on T1- or T2-weighted MR images in the following locations: torus uterinus, uterosacral ligaments (USLs), vagina, rectovaginal septum, rectosigmoid, and bladder. MR imaging results were compared with surgical and pathologic findings. Sensitivity, specificity, predictive values, and accuracy of MR imaging for prediction of deep pelvic endometriosis were assessed. RESULTS Pelvic endometriosis was confirmed at pathologic examination in 163 (83.6%) of 195 patients. Endometriomas, peritoneal lesions, and deep pelvic endometriosis were diagnosed on the basis of surgical findings, alone or combined with pathologic findings, in 111 (68.1%), 83 (50.9%), and 103 (63.2%) of 163 patients, respectively. Torus uterinus and USL were the most frequent sites of deep pelvic endometriosis. The sensitivity, specificity, positive and negative predictive values, and accuracy of MR imaging for deep pelvic endometriosis were 90.3% (93 of 103), 91% (84 of 92), 92.1% (93 of 101), 89% (84 of 94), and 90.8% (177 of 195), respectively. The sensitivity, specificity, and accuracy, respectively, of MR imaging for the diagnosis of endometriosis in specific sites were as follows: USL, 76% (57 of 75), 83.3% (100 of 120), and 80.5% (157 of 195); vagina, 76% (16 of 21), 95.4% (166 of 174), and 93.3% (182 of 195); rectovaginal septum, 80% (eight of 10), 97.8% (181 of 185), and 96.9% (189 of 195); rectosigmoid, 88% (53 of 60), 97.8% (132 of 135), and 94.9% (185 of 195); and bladder, 88% (14 of 16), 98.9% (177 of 179), and 97.9% (191 of 195). CONCLUSION MR imaging demonstrates high accuracy in prediction of deep pelvic endometriosis in specific locations.
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Affiliation(s)
- Marc Bazot
- Department of Radiology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4 rue de la Chine, Paris 75020, France.
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Doniec JM, Kahlke V, Peetz F, Schniewind B, Mundhenke C, Löhnert MS, Kremer B. Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management. Dis Colon Rectum 2003; 46:1667-73. [PMID: 14668593 DOI: 10.1007/bf02660773] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE In patients with histopathologically proven or suspected endometriosis with possible involvement of the rectum, endorectal ultrasound was performed to determine the sensitivity and specificity of this method with regard to rectal wall involvement and the impact on the following operation. METHODS In an historical cohort analysis, 85 females with histopathologically proven or suspected endometriosis with possible involvement of the rectum were treated between 1992 and 2001. Endorectal ultrasound was performed with a 7.5 MHz real-time unit, and results of endorectal ultrasound were compared with intraoperative findings and histopathologic diagnosis of 65 patients undergoing operation. A questionnaire was used to evaluate postoperative signs and symptoms. RESULTS Of 65 patients undergoing surgery, 37 underwent laparotomy with 25 resections of the bowel and 28 laparoscopy. In 31 of 32 patients with suspected rectal wall infiltration, preoperative endorectal ultrasound diagnosis was confirmed. In patients in whom endorectal ultrasound showed no rectal wall involvement, histopathology revealed infiltration in one patient, leading to sensitivity of 97 percent and specificity of 97 percent with regard to rectal wall involvement. In terms of the deepness of rectal wall infiltration, endorectal ultrasound had a sensitivity of 76 percent with regard to infiltration of the muscularis propria and 66 percent for infiltration of the submucosa. Operations led to a significant (P < 0.05) reduction of preoperative symptoms by approximately 60 percent. CONCLUSIONS Endorectal ultrasound is a useful, noninvasive technique for preoperative evaluation of possible rectal wall involvement in endometriosis. Based on the high sensitivity and specificity, recommendation for laparotomy and bowel resection in cases with suspected rectal involvement can be facilitated.
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Affiliation(s)
- J Marek Doniec
- Department for General and Thoracic Surgery, University of Kiel, Arnold-Heller-Strasse 7, 24105 Kiel, Germany
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Dessole S, Farina M, Rubattu G, Cosmi E, Ambrosini G, Nardelli GB. Sonovaginography is a new technique for assessing rectovaginal endometriosis. Fertil Steril 2003; 79:1023-7. [PMID: 12749448 DOI: 10.1016/s0015-0282(02)04952-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the efficacy of a new technique, the sonovaginography, for the assessment of rectovaginal endometriosis. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Forty-six women were scheduled for laparotomic or laparoscopic surgery because of rectovaginal endometriosis suspected on the basis of patient history and/or clinical examination. INTERVENTION(S) Before surgery, all the women underwent transvaginal ultrasonography and then sonovaginography. The latter is based on transvaginal ultrasonography combined with the introduction of saline solution to the vagina that creates an acoustic window between the transvaginal probe and the surrounding structures of the vagina. Ultrasound findings were compared with the results of surgical exploration and histological examination. MAIN OUTCOME MEASURE(S) We assessed the accuracy of transvaginal ultrasonography and of sonovaginography for the detection and the location and extension assessment of rectovaginal endometriotic lesions, as well as compared patient compliance between the procedures. RESULT(S) Sonovaginography diagnosed rectovaginal endometriosis more accurately than did transvaginal ultrasonography, with a sensitivity and specificity of 90.6% and 85.7%, respectively, whereas the transvaginal ultrasonography has shown a sensitivity and specificity of 43.7% and 50%, respectively. Patient discomfort did not differ significantly between the procedures. CONCLUSION(S) Sonovaginography is a reliable and simple method for the assessment of rectovaginal endometriosis and provides information on location, extension, and infiltration of the lesions, which are important factors in selecting the kind of surgery.
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Affiliation(s)
- Salvatore Dessole
- Department of Pharmacology, Gynecology and Obstetrics, University of Sassari, Sassari, Italy.
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Chapron C, Dubuisson JB, Pansini V, Vieira M, Fauconnier A, Barakat H, Dousset B. Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2002; 9:115-9. [PMID: 11960033 DOI: 10.1016/s1074-3804(05)60117-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. MEASUREMENTS AND MAIN RESULTS Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). CONCLUSION High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term "deep endometriosis infiltrating the rectovaginal septum" is generally incorrect in the true anatomic sense.
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Affiliation(s)
- Charles Chapron
- Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, C.H.U. Cochin Port-Royal, 123 Bld Port-Royal, 75014 Paris, France
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