We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis compared with alternative treatments. Moreover, we aimed to assess the risks of operative laparoscopy compared with those of alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision making around surgery. Data Sources: We searched MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. In addition, a manual search of reference lists of relevant studies was conducted. Methods of Study Selection: Published and unpublished randomized controlled trials (RCTs) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible. Tabulation, Integration, and Results: In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies of interest were identified to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at 6 months compared with diagnostic laparoscopy (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61−4.34; p <.001; 2 RCTs, 102 participants; low-quality evidence). Because the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference regarding clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99−1.92; p = .06; 4 RCTs, 624 participants; moderate-quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared with diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84−4.65; p = .12; 5 RCTs, 554 participants; very-low-quality evidence). No studies reported on the progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and locations in asymptomatic women with endometriosis. We Ben W. Mol reports consultancy for OvsEva, Guerbet, and Merck; grant support from Merck; travel support from Guerbet; and holds a Practitioner Fellowship from National Health and Medical Research Council. Tal Z. Jacobson reports a minor shareholding in, and clinical service fees from, Virtus Health. Neil P. Johnson reports consultancy for Myovant Sciences, Vifor Pharma, and Guerbet and research funding from AbbVie and Myovant Sciences. All remaining authors declare they have no conflict of interest.

Objectives-To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations. Methods-We performed a prospective study between December 2017 and December 2018. Three fellows (F1-F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results-A total of 150 examinations were performed on 145 patients. Twentysix (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%-94%). The overall accuracy of POD state classification was 93% (range, 90%-96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans. Conclusions-Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.

Objectives-To evaluate the learning curve of gynecologic surgical fellows (ie, in training) to properly identify the ureters in real time while simultaneously performing and interpreting transvaginal ultrasound (TVUS) examinations. Methods-We performed a prospective study, which took place at 2 centers in Sydney, Australia, from December 2017 to December 2018. Three fellows (F1-F3), of varying prestudy ultrasound (US) experience, were recruited to participate. One hundred fifty predetermined examinations were planned. A TVUS examination was performed by the study reference standard (an expert in gynecologic US). Subsequently, the fellows performed a focused component to identify bilateral ureters, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's evaluations were complete. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results-A total of 150 examinations were performed on 145 patients. One patient had a single ureter, and 1 patient had US evidence of hydroureter. The cumulative summation test for the learning curve for bilateral ureter identification showed that F1 did not reach competency by 50 TVUS examinations, whereas F2 and F3 required 41 and 31 TVUS examinations to reach competency, respectively. Conclusions-Contrary to other studies on the topic, this study suggests that although it is feasible for surgical fellows to learn TVUS identification of bilateral ureters, not all fellows can reach competency during a program based on a predefined number of scans. We advocate for an individualized, competencybased medical education model in learning US for identifying the ureters.