Role of preoperative ultrasound mapping in the surgical management of deep infiltrating endometriosis: a prospective observational study

Abstract

Background Endometriosis is a challenging gynecological condition that has a profound influence on the quality of life of affected women. Transvaginal ultrasound is considered the first-line imaging method in preoperative assessment of the extent and severity of endometriosis. Accurate preoperative mapping can aid the surgeon in patient counselling, selection of the most appropriate surgical method that minimizes the operative and post-operative complications. The aim of our study is to evaluate the accuracy of transvaginal sonography (TVS) in precisely assessing the size, location and extent of deep infiltrating endometriosis (DIE) using a new modified endometriosis mapping proforma with histopathological confirmation. Our prospective observational study included 101 women with clinically suspected DIE who underwent TVS followed by laparoscopy from October 2018 to December 2020 with a maximum of 4 weeks interval. Precise mapping of DIE was done during TVS and laparoscopy. Results were correlated with histopathology findings. Results DIE was confirmed by histopathology in 88 patients. Sensitivity and specificity for individual DIE locations were rectovaginal septum 67.9% and 98.6%; vagina 52.2% and 98.7%; uterosacral ligaments 82.5% and 96.2%; torus 96.4% and 97.3%; parametrium 68.8% and 96.9%; rectum 100% and 98.8%; bladder 100% and 100%, ureters 63.4% and 99.0%; scar endometriosis 100% and 100%; pouch of Douglas obliteration 97.7% and 100%. No statistically significant difference was detected between ultrasound and histopathology size. Ultrasound tended to underestimate the lesion size; the underestimation was more pronounced for lesions > 3 cm. “Butterfly” and “tram-track” signs are two new sonographic signs related to posterior compartment DIE. No post-operative complications were recorded. There were no cases of DIE recurrence. Eleven out of 22 cases of infertility achieved pregnancy during 18 months follow-up. Conclusion TVS provides a thorough and accurate evaluation of the extent of endometriosis. An experienced radiologist can use E-PEP to provide an accurate demonstration of the location and extent of DIE which helps the surgeon select the most appropriate surgical approach ensuring radical treatment of the disease and minimizing short- and long-term complications.

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.…”

“…El‐Maadawy et al 40 described 2 new sonographic signs that were associated with bilateral USL involvement showing TU plaques called the “butterfly” and “tram‐track” signs. The butterfly configuration is seen in the transverse plane with bilateral USL DE showing torus plaques.…”

“…A limitation of the included articles was that many papers had insufficient data. Some scan methodologies show promise but had low participation numbers 26,35,36,39,40 . No papers included a power analysis, 35 and there was inconsistent reporting of data, which places uncertainty on the quality of the results.…”

“…When performing diagnostic tests for endometriosis, the outcome relies on level of skill and experience of the operator undertaking the reference test. 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.…”

“…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.…”