Comparison Between Sonography-Based and Surgical Evaluation of Endometriotic Lesions Using the #Enzian Classification – A Retrospective Data Analysis

Abstract

Purpose To compare the location and sizes of deep endometriosis (DE) lesions evaluated by preoperative transvaginal sonography (TVS) in different #Enzian compartments with intraoperatively assessed DE location and size. Materials and Methods Retrospective data analysis of 93 women undergoing TVS and surgery for DE in 2019 at a tertiary referral center for endometriosis. Results #Enzian compartment C (rectum) showed the highest rate of exact concordance with 74% of cases, which increased to 87% when a tolerance margin of a maximum of 3mm for TVS measurements was taken into account. For compartment B (uterosacral ligaments, parametria) and compartment A (vagina, rectovaginal space), the rates of exact concordance were slightly lower. In compartment O (ovary), high exact concordance rates similar to those observed for compartment C were observed. In compartment T (tubo-ovarian unit), most reliable estimations were seen for slight (TVS T1) and severe adhesions (TVS T3). There were only a few cases of missed lesions as well as false positives on TVS: Sensitivity was 100% for all compartments except for A and B left (97%) and FB (urinary bladder, 86%); specificity was 100% for FB, FI (other intestinal locations), FU (ureters) and O right, 86%-98% for A, B right, C, O left and FO (other extragenital lesions) and 70% for B left. Conclusion The preoperative evaluation of the location and size of DE lesions by TVS in different #Enzian compartments is accurate, providing a detailed presurgical description of the extent of ovarian and deep endometriosis and associated minor or severe adhesions.

Accuracy of sonography for non‐invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study

“…In conclusion, the findings of the present study confirm preliminary data 19 showing that preoperative assessment of the localization and severity grade of endometriotic lesions/adhesions, as described according to the #Enzian classification, can be carried out with high accuracy using ultrasound. This provides further evidence that the #Enzian classification can be used by both sonographers and surgeons to describe endometriotic lesions.…”

“…In line with the findings of a previous retrospective study using the #Enzian classification to evaluate endometriotic lesions and adhesions 19 , difficulties in the diagnosis of tubo‐ovarian adhesions were observed in the current study. Mild tubo‐ovarian adhesions on TVS (corresponding to T1) were diagnosed as severe at surgery (i.e.…”

“…A recent retrospective analysis from a single tertiary referral center 19 of ultrasound imaging data and surgical findings in women with DE showed a high overall diagnostic accuracy of presurgical transvaginal sonography (TVS) supplemented with transabdominal sonography (TAS) for detecting endometriotic lesions or adhesions and determining their size and severity grade in different compartments, as described using the #Enzian classification. The aim of the present work was to further evaluate the applicability and accuracy of TVS/TAS using the #Enzian classification for the assessment of endometriosis before radical surgery for DE in a large, prospective international tertiary referral multicenter setting.…”

Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis

“…Instead of combining different classification systems, a single system such as the #Enzian classification can be used for both non-invasive and invasive diagnostics [50]. Di Giovanni et al [54] retrospectively investigated 93 patients undergoing TVS and surgery using Fig. 8 Image of a deep nodule presenting a full thickness defect in the anterior rectum wall with prominent spikes towards the bowel lumen with extrinsic reaction (hypodense area; zig-zagged shaped) Fig.…”

“…The authors advocate for using of TVS as a primary tool to evaluate women with suspected endometriosis and to stratify these patients into low-and high-risk patients based on the results of TVS-based preoperative assessment. A nearly complete Table 1 The accuracy of sonographic classification (#Enzian(u)) of endometriosis compared with the result of surgical classification #Enzian(s) (retrospective study by di Giovanni A. et al [54] and prospective study of Montanari E. [19]) O = ovary; T = adhesions of the adnexa; A = vagina, rectovaginal septum, torus uteri; B = USL, parametrium; C = rectum; FB = bladder; FI = intestinal above the rectosigmoid (> 16 cm from the anus); FU = ureteral obstruction; FO = other lesions *For #Enzian compartment T, it was not possible to calculate sensitivities and specificities, as there were too few cases without any lesion during TVS or surgery di Giovanni et non-invasive diagnosis of endometriosis opens up new perspectives for conservative and surgical treatment. Using the #Enzian classification, also in the context of sonographic assessment, provides clinicians with a uniform "language" for a comprehensive and easily reproducible description of endometriosis.…”