Ovarian Immobility at Transvaginal Ultrasound: An Important Sonographic Marker for Prediction of Need for Pelvic Sidewall Surgery in Women With Suspected Endometriosis

Abstract

Objectives-To determine whether ovarian fixation at transvaginal ultrasound (TVU) is a marker for a need for laparoscopic pelvic sidewall surgery (ie, ureterolysis or dissection of adhesions involving the pelvic sidewall). The relationship between ovarian immobility at TVU with respect to endometriosis staging using the revised American Fertility Society (r-AFS) classification was also evaluated.Methods-Retrospective diagnostic accuracy study was performed in a tertiary referral hospital and two private hospitals. Sixty-six women with pelvic pain underwent detailed TVU preoperatively followed by laparoscopic endometriosis surgery. TVU ovarian mobility findings (ie, mobile versus fixed ovary) were compared to surgical findings, the need for laparoscopic pelvic sidewall surgery and r-AFS score (I-IV).Results-Complete ultrasound and surgical data were available for 66 of 77 (86%) women. Twenty-six of 66 (40%) had isolated superficial peritoneal endometriosis, 15 of 66 (23%) had ovarian endometrioma (OE), 13 of 66 (20%) had pelvic deep endometriosis (DE). Twenty-seven of 66 (41%) had ovarian fixation at TVU. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of ovarian fixation at TVU for the prediction of need for laparoscopic pelvic sidewall surgery was 71%, 61%, 86%, 85%, and 62%, respectively (P = .0002). Ovarian fixation at TVU was significantly associated with the presence of ipsilateral OE, pouch of Douglas obliteration, pelvic DE nodules, and r-AFS stage III/IV (moderate/severe) endometriosis (all P-values <.05).Conclusions-Ovarian fixation at TVU appears to be a marker for moderate/ severe endometriosis and the need for laparoscopic pelvic sidewall surgery. This sign may be a valuable "red flag" for identifying women at increased risk of requiring an advanced laparoscopic surgeon, and in turn, improve surgical planning.

What is the accuracy of transvaginal ultrasound for endometriosis mapping prior to surgery when performed by a sonographer within an outpatient women's imaging centre?

“…Given the scant evidence supporting a statistically significant association between SST and endometriosis, we would suggest that tenderness be used as proposed by Guerriero et al 41 to guide sonographers or sonologists towards areas that should be assessed carefully for sonographic signs of endometriosis of any subtype, rather than as a reportable marker. As ovarian immobility has been shown to have a high association with DE, 42 routine testing of ovarian mobility at the time of all TVUS examinations is a useful tool. If poor mobility is detected, this should prompt performance of a comprehensive TVUS assessment for DE, or an onreferral for such imaging if extension of scanning is not possible.…”

Pathophysiology, diagnosis, and management of endometriosis

“…In many cases, endometriosis is present at the site of ovarian fixation. 130 Deep endometriosis appears as multifocal nodules and may infiltrate the surrounding viscera and peritoneal tissue. 131 Almost 40% of laparoscopies done for pelvic pain do not identify any pathology.…”

“…Adhesions are often found in association with endometriomas and consist of fibrous scar tissue resulting from chronic inflammation. In many cases, endometriosis is present at the site of ovarian fixation 130. Deep endometriosis appears as multifocal nodules and may infiltrate the surrounding viscera and peritoneal tissue 131.…”

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

“…Ovarian immobility at the time of TVS is another important soft marker that has been associated with OE 84,85 , posterior-compartment DE 86 and ipsilateral SE [87][88][89] , as ipsilateral pelvic sidewall SE is less likely to be present in people with a mobile ovary (in the absence of DE or OE) 89 . Ovarian immobility to the pelvic sidewall is important to identify, using preoperative TVS, for patient counseling and surgical planning, as these women are at increased risk of requiring pelvic sidewall adhesiolysis and ureterolysis 90 .…”