A prospective study comparing rectal water contrast‐transvaginal ultrasonography with sonovaginography for the diagnosis of deep posterior endometriosis

Abstract

Introduction: Preoperative assessment of deep endometriotic (DE) nodules is necessary to inform patients about the possible treatments and provide informed consent in case of surgery. This study aims to investigate the diagnostic performance of rectal water-contrast transvaginal ultrasonography (RWC-TVS) and sonovaginography (SVG) in women with suspicion of posterior DE. Material and methods: This prospective comparative study (NCT04296760) enrolled women with clinical suspicion of DE at our institution (Piazza della Vittoria 14 SRL, Genoa, Italy). Exclusion criteria were the previous diagnosis of DE by imaging techniques or laparoscopy. All patients underwent RWC-TVS and SVG, independently performed by two gynecologic sonologists blinded to the other technique's results. Patients underwent laparoscopic surgery within the following three months; imaging findings were compared with surgical and histological results. Results: In 208 out of 281 (74.0%) patients included, posterior DE was surgically confirmed in rectosigmoid (n=88), vagina (n=21), rectovaginal septum (n=34), and uterosacral ligaments (n=156). RWC-TVS and SVG demonstrated similar sensitivity (SE; 93.8% vs 89.4%; p=0.210) and specificity (SP; 86.3% vs 79.4%; p=0.481) in diagnosing posterior DE. Specifically, both exams had similar accuracy in detecting nodules of uterosacral ligaments (p=0.779), vagina (p=0.688) and rectovaginal septum (p=0.824). RWC-TVS had higher SE (95.2% vs 82.0%; p=0.003) and similar SP (99.5% vs 98.5%; p=0.500) in diagnosing rectosigmoid endometriosis Accepted ArticleThis article is protected by copyright. All rights reserved and estimated better infiltration of intestinal submucosa (p=0.039), and distance between these nodule and anal verge (p < 0.001); only RWC-TVS allowed the estimation of bowel lumen stenosis. A similar proportion of discomfort was experienced during both exams (p=0.191), although a statistically higher mean VAS score was reported during RWC-TVS (p<0.001). Conclusions:Although RWC-TVS and SVG have similar accuracy in the diagnosis of DE, RWC-TVS has a higher performance in assessing the characteristics of rectosigmoid endometriosis.

Ultrasound Characteristics and Scanning Techniques of Uterosacral Ligaments for the Diagnosis of Endometriosis

“…Abnormal characteristics of USLs were reported consistently in 20 studies 1,14,16,24–31,33,35–42 . While generally the criteria were in agreement, the descriptors used were inconsistent and varied with no interobserver agreement.…”

“…Most papers do not report clearly the experience of teams involved or the number of surgeons used, and while many of the techniques used have reported high outcomes, only descriptive reporting was used with no interobservational or intraobservational validation 28,32,34,37,38,40 . Ultrasound characteristics of USLs have been described via a range of techniques including TVS, 1,14,16,24–42 3D ultrasound, 31,38,39 sonovaginography (SVG), 26,41 TVS magnetic resonance imaging (MRI) fusion, 34 transrectal ultrasound (TRUS), 40 rectal water‐contrast TVS (RWC‐TVS), 41 and rectal endoscopic sonography (RES) 33 (Table 2), with consensus seen among different approaches.…”

“…Lastly, there was only 1 paper 41 that described the ethnicity of patients so it is unknown that the results are reproducible across different ethnic backgrounds.…”

“…A summary of the ultrasound characteristics used for the diagnosis of USL in the reviewed articles is in Table 5. Although most papers (20/22) 1,14,16,[24][25][26][27][28][29][30][31]33,[35][36][37][38][39][40][41][42] described the diagnostic criteria they used for an abnormal or diseased USL, many failed to determine what the normal USL appearance is or outline what measurement techniques were applied. In total, only 5 papers 27,28,35,36 described a normal USL.…”

Advances in Imaging for Assessing Pelvic Endometriosis

“…Although RWC-TVUS and SVG have similar accuracies in the diagnosis of DE, RWC-TVUS has a higher performance when assessing the characteristics of rectosigmoid endometriosis. Like conventional TVUS, a limitation of enhanced TVUS techniques is that they cannot diagnose endometriotic nodules located above the rectosigmoid, as they are beyond the field of view of ultrasonography [ 45 ]. Additional evaluation through the abdominal wall using a high-resolution linear transducer might be needed in some cases, for example, to assess cecal or appendicular endometriosis.…”