Evaluation of Uterosacral Ligament Involvement in Deep Endometriosis by Transvaginal Ultrasonography

Best Practices: Ultrasound Versus MRI in the Assessment of Pelvic Endometriosis

Endometriosis is a common yet morbid disease. Imaging plays an important role in diagnosis and treatment planning. Both ultrasound (US) and MRI are used to detect disease. We performed a literature review to assess whether one is superior. A total of 33 studies from the 4482 identified in the initial search were found to assess the efficacy of US and/or MRI in detecting pelvic endometriosis. Most studies were performed at centers with extensive experience with endometriosis, using dedicated US and MRI protocols. A wide range of sensitivities and specificities was reported, but overall weighted means of diagnostic statistics between US and MRI were similar. The choice of dedicated US versus MRI in evaluation of endometriosis should therefore be based on the expertise in the region. The data also showed US had better accuracy for identifying depth of wall invasion in bowel wall disease, whereas MRI better visualized pelvic wall and extraperitoneal disease. Routine US and MRI protocols performed worse than dedicated US and MRI protocols, which may account for delays in diagnoses. Clinical and research efforts directed at improving the sensitivity of routine imaging for diagnosing deep endometriosis could improve patient access to appropriate care.

Prospective diagnostic test accuracy of transvaginal ultrasound posterior approach for uterosacral ligament and torus uterinus deep endometriosis

OBJECTIVE

To determine the diagnostic test accuracy of transvaginal ultrasound (TVS) using a standardized technique for the diagnosis of deep endometriosis (DE) of the uterosacral ligaments (USLs) and adjacent torus uterinus (TU).

METHODS

This was a prospective diagnostic test accuracy study conducted at the McMaster University Medical Center Tertiary Endometriosis Clinic, Hamilton, ON, Canada. Consecutive participants were enrolled if they successfully underwent TVS and surgery by our team from 10 August 2020 to 31 October 2021. The index test was TVS using a standardized posterior approach performed and interpreted by an expert sonologist. The reference standard included direct surgical visualization on laparoscopy by the same person who performed and interpreted the ultrasound scans. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios were calculated for the TVS posterior approach for each location using the reference standard.

RESULTS

There were 54 consecutive participants included upon completion of laparoscopy and histological assessment. The prevalence of DE for the left USL, right USL and TU was 42.6%, 22.2% and 14.8%, respectively. Based on surgical visualization as the reference standard, TVS demonstrated an accuracy of 92.6% (95% CI, 82.1-97.9%), sensitivity of 82.6% (95% CI, 61.2-95.1%), specificity of 100% (95% CI, 88.8-100%), PPV of 100% and NPV of 88.6% (95% CI, 76.1-95.0%) for diagnosing DE in the left USL. For DE of the right USL, TVS demonstrated an accuracy of 94.4% (95% CI, 84.6-98.8%), sensitivity of 75.0% (95% CI, 42.8-94.5%), specificity of 100% (95% CI, 91.6-100%), PPV of 100% and NPV of 93.3% (95% CI, 84.0-97.4%). For DE of the TU, TVS demonstrated an accuracy of 100% (95% CI, 93.4-100%), sensitivity of 100% (95% CI, 63.1-100%), specificity of 100% (95% CI, 92.3-100%), PPV of 100% and NPV of 100%.

CONCLUSIONS

We observed high diagnostic test accuracy of the evaluated standardized TVS technique for assessing DE of the USLs and TU. Further studies evaluating this technique should be performed, particularly with less experienced observers, before considering this technique as the standard approach. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Biomarkers of endometriosis

Endometriosis is one of the most severe female reproductive disorders, affecting 6-10% of women between 18 and 35. It is a gynaecological condition where endometrial tissue develops and settles outside the uterus. The aetiology of endometriosis is primarily influenced by genetic, epigenetic, and non-genetic variables, making it highly challenging to create a therapeutic therapy explicitly targeting the ectopic tissue. The delay in the treatment is due to the limitations in the diagnostic approaches, which are restricted to invasive techniques such as laparoscopy or laparotomy. This accords to 70% of the women being diagnosed at later stages. By understanding the subject, several treatment medications have been produced to lessen the disease's symptoms. Nevertheless, endometriosis cannot be permanently cured. A viable or persuasive standard screening test for endometriosis must be utilized in a clinical context. A helpful assessment method for the early identification of endometriosis could be biomarkers. A major research priority is the identification of a biomarker that is sensitive and specific enough for detecting endometriosis. The present article has reviewed studies published on the expression of biomarkers of endometriosis. It outlines various biomarkers from different sample types, such as serum/plasma and urine, in addition to tissue. This would provide a non-invasive approach to diagnosing the disease at the initial stages without any harmful repercussions. Future high-throughput advances in science and technology are anticipated to result in the creation of a potent remedy for endometriosis. To achieve successful outcomes, it is necessary to research the discussed biomarkers that demonstrate substantial results extensively.

Diagnostic Accuracy of Transvaginal Sonography for Deeply Infiltrating Endometriosis and Pouch of Douglas Obliteration in the Presence or Absence of Ovarian Endometrioma

Background: Endometriosis is one of the most common gynecological diseases worldwide. Significant attention has been drawn to this multiorgan and often painful disorder. Objectives: This study aimed to examine the accuracy of transvaginal sonography (TVS) in the diagnosis of deeply infiltrating endometriosis (DIE) with respect to the presence or absence of ovarian endometrioma (OE). Patients and Methods: This cross-sectional study was performed on all patients undergoing TVS before gynecological laparoscopy. With pathological confirmation as the standard reference, the diagnostic accuracy of TVS for DIE and pouch of Douglas (POD) obliteration was compared with that of laparoscopy in the anterior and posterior pelvic compartments with respect to the presence or absence of OE. Agreement between TVS and laparoscopy was evaluated for each case, and Cohen’s kappa statistic was measured for each site of involvement. Moreover, sensitivity, specificity, negative and positive predictive values, and likelihood ratios of TVS were calculated, with laparoscopy as the reference test. Results: A total of 110 patients, with a mean age of 37.20 ± 7.16 years, were recruited in this study. The accuracy, sensitivity, and negative predictive value of TVS for the diagnosis of DIE and POD obliteration were estimated at 89.5%, 58.3%, and 88.9% in the anterior pelvic compartment and 93.3%, 92%, and 70.6% in the posterior pelvic compartment, respectively. Nevertheless, TVS showed lower sensitivity for detecting pelvic adhesions and peritoneal cysts compared to laparoscopy. The presence of OE did not significantly increase the accuracy of TVS for the diagnosis of DIE or POD obliteration (P > 0.05). Conclusion: The present study showed that TVS is an adequately accurate and non-invasive diagnostic tool for the detection and mapping of DIE and POD obliteration, regardless of the presence of OE. TVS may waive the need for exploratory laparoscopy in DIE or at least facilitate precise pre-procedural DIE mapping.

Ultrasound Evaluation of Retrocervical and Parametrial Deep Endometriosis on the Basis of Surgical Anatomical Landmarks

STUDY OBJECTIVES

To assess the value of combined transvaginal/transabdominal (TV/TA) ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas, and summarize the features and anatomical criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments.

DESIGN

Retrospective study.

SETTING

A specialized endometriosis center in Avellino, Italy PATIENTS: A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention.

INTERVENTIONS

Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals (CIs).

MEASUREMENTS AND MAIN RESULTS

A total of 4,983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97%-98% and 98%-100%, respectively, for both retrocervical (torus uterinus, uterosacral ligaments insertion) and parametrial lesions.

CONCLUSION

Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.

Diagnostic delay of endometriosis in adults and adolescence-current stage of knowledge

PURPOSE

The purpose of this article is to provide a modern perspective on the diagnosis of endometriosis with particular attention to the role of ultrasound examination. In the present study, we highlight the problem of endometriosis in teenage girls and discuss the patients' perspective on the diagnostic process.

METHODS

In order to present the most recent reports on the diagnosis of endometriosis, the PubMed database was searched. Articles published within the last 3 years (2019-2021) and those considered relevant during the bibliographic review were analyzed.

RESULTS

The role of ultrasound examination and assessment of patients' perspective related to delayed and incorrect diagnosis were considered to be the most important in the recent reports. Attention was also paid to the problem of endometriosis diagnosis in adolescent girls.

CONCLUSIONS

Appropriately constructed and used questionnaires help to determine the risk of endometriosis in a particular patient. The primary method for diagnosis is extended ultrasound examination, which should be performed especially in patients with a high risk of developing the disease. This procedure is applicable to both adult and adolescent women. Awareness of the possibility of developing the disease in a particular patient, combined with appropriate use of ultrasound examination, can contribute to the decrease in diagnostic delay.

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.

Diagnostic value of different color ultrasound diagnostic method in endometrial lesions

BACKGROUND

Endometrial lesions include endometrial cancer and inferior fibroids. Among them, endometrial cancer as a malignant tumor seriously endangers the life and health of patients. Ultrasonography is an important means of diagnosing female reproductive system diseases, and it is of critical value for the early diagnosis of endometrial cancer. However, different ultrasound inspection programs have achieved different results. It is of great significance to choose a suitable inspection program.

AIM

To explore the diagnostic efficacy of different ultrasonic examination methods in clinical endometrial lesions.

METHODS

The 140 patients with endometrial lesions who were treated in our hospital from April 2018 to October 2019 were used as the research subjects. All patients underwent transvaginal color ultrasound and transabdominal color ultrasound. We compared the diagnostic coincidence and image display effects of the two different examination methods, and the endometrial thickness, blood flow, uterine effusion and resistance index of different diseases were observed by transvaginal color ultrasound.

RESULTS

The diagnostic coincidence rate of all types of diseases of transvaginal color ultrasound was significantly higher than that of transabdominal color ultrasound (P = 0.001, 0.005, 0.001 and 0.001). In addition, the excellent and good rate of image display of transvaginal color ultrasound was higher than that of transabdominal color ultrasound (P = 0.001). There were significant differences in endometrial thickness in patients with different types of endometrial lesions through the transvaginal color examination (P = 0.001). The incidence rate of uterine effusion in patients with endometrial carcinoma was significantly higher than that in patients with other types of endometrial lesions (P = 0.001), and the rate of the blood flow was the highest (P = 0.001). The comparison of blood flow resistance index indicated that the blood flow resistance index in endometrial cancer patients was the lowest, which shows that the difference was statistically significant (P = 0.001).

CONCLUSION

The overall diagnostic efficacy of transvaginal color ultrasound in the clinical diagnosis of endometrial lesions is better than that of transabdominal color ultrasound, which held higher diagnostic coincidence rate and image display effect. There were significant differences in the thickness of the endometrium and the blood flow in different types of lesions.

Accuracy of transvaginal ultrasound for diagnosis of deep infiltrating endometriosis in the uterosacral ligaments: Systematic review and meta-analysis

OBJECTIVES

To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of uterosacral ligaments (USL) in patients with clinical suspicion of deep infiltrating endometriosis (DIE).

METHODS

Extensive searches were conducted in PubMed, EMBASE and Cochrane libraries to search studies published between January 1989 and September 2, 2019. The inclusion criteria were the preoperative assessment of USL endometriosis by TVS in patients with clinically suspected DIE, using laparoscopy and histological results as the reference standard. The assessment of research quality uses preferred reporting items, including the System Review and Meta Analysis (PRISMA) guidelines, as well as the quality assessment of diagnostic accuracy study 2 (QUADAS-2) tools.

RESULTS

During our advanced search, 7562 studies were identified. Finally, 11 of which were recognized as qualified and incorporated into this study. The pooled sensitivity, specificity, positive probability ratio (LR+) and negative probability ratio(LR-) of TVS for detecting DIE in the USL were 65 %(95 %CI:43-83), 92 %(95 %CI:84-96), 7.80 (95 %CI:4.7-13.0) and 0.38(95 %CI:0.22-0.66), respectively. There was significant heterogeneity in sensitivity (I²: 97.40 %; Cochran Q, 385.09; P<0.001) and specificity (I², 93.89 %; Cochran Q, 163.75; P < 0.001).

CONCLUSION

TVS provides an excellent comprehensive diagnostic performance for DIE of the USL. However, further research is required to improve the diagnostic quality.

Encyclopedia of endometriosis: a pictorial rad-path review

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.

Transvaginal US of Endometriosis: Looking Beyond the Endometrioma with a Dedicated Protocol

Transvaginal sonography (TVS) is a valuable primary imaging tool for the initial evaluation and management of endometriosis, a complex multifocal disease process with a varied spectrum of clinical and morphologic features that can substantially affect quality of life. The high accuracy of TVS for the detailed mapping of disease extent, an essential process for guiding treatment strategies, is well documented. The dynamic nature of US provides added value, revealing information that is not easily addressed with other imaging modalities. As recognized by the International Deep Endometriosis Analysis Consensus Group, a dedicated standardized protocol that is used by experienced and knowledgeable operators is necessary for a complete evaluation. The four components of a dedicated TVS protocol for evaluation of pelvic endometriosis are (a) evaluation of the uterus and adnexa, (b) dedicated search for deep infiltrating endometriosis, (c) assessment of the sliding sign, and (d) detection of sonographic soft markers. These components are described, and the multiple locations and US findings of endometriosis within the pelvis are reviewed, with emphasis on the unique features of US as an extension of the physical examination. In addition to enabling evaluation of the static findings of adenomyosis, endometrioma, hydrosalpinx, hematosalpinx, and hypoechoic nodules of deep infiltrating endometriosis, dynamic TVS enables assessment of pouch of Douglas obliteration, organ mobility, and site-specific tenderness, as well as tenderness-guided imaging. The benefits of implementing a dedicated TVS protocol in terms of improved patient care are also discussed. Online supplemental material is available for this article. ^©RSNA, 2019.