Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on a review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counselling and planning of surgical treatment strategies.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence­based and clinically relevant statements on the use of imaging techniques for non­invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counseling and planning of surgical treatment strategies

Non-Invasive Imaging Techniques for Diagnosis of Pelvic Deep Endometriosis and Endometriosis Classification Systems: An International Consensus Statement.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counseling and planning of surgical treatment strategies.

Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), ESHRE, the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers, and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counselling, and planning of surgical treatment strategies.

Safety of methotrexate administration in women with pregnancy of unknown location deemed to have high risk of ectopic pregnancy.

OBJECTIVES: This study evaluates the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have high risk of underlying ectopic pregnancy (EP) and to investigate whether this would result in inadvertent exposure of MTX to viable intra-uterine pregnancy (IUP). METHODS: A retrospective observational study was conducted on clinically stable women who were classified PUL at Early Pregnancy Unit, Nepean Hospital, between 2007 and 2021. PUL is defined as when a woman presents with a positive pregnancy test but has no signs of IUP or EP on the transvaginal ultrasound (TVS). If patients with a PUL behave biochemically like an EP but the location is not confirmed on ultrasound, these women are eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of American College of Obstetricians and Gynaecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians & Gynaecologists (RCOG) and National Institute for Health Care Excellence (NICE) were applied to the collected PUL database. The number of patients eligible to receive MTX and the number of women with underlying viable IUP who would be inadvertently given MTX were calculated. RESULTS: A total of 816 consecutive women with PUL were reviewed, and 724 had complete data and were included in the final analysis. 6 patients were persistent PULs, and 718 fell among outcomes of 4 subgroups: viable IUP, non-viable IUP, EP, failed PUL. According to the ACOG, ASRM, RCOG and NICE, the rate of possible MTX administration among patients with a PUL is 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no single persistent-PUL would have received MTX according to the above protocols, and majority of the MTX treatment were unnecessary because those patients were classified as NVIUP or FPUL later. More importantly, ACOG and ASRM could theoretically result in inadvertent MTX administration to women with an underlying IVUP at rates of 4.1/1000 (3/724). CONCLUSIONS: Current guidelines used to predict high risk of EP among PUL population are not safe enough to avoid inadvertent MTX administration to women with an underlying viable IUP. These guidelines need to be wisely used to ensure that no wanted pregnancy is exposed to MTX. Women with PULs should be carefully monitored and MTX should be used with judicious care when the location of pregnancy is yet to be confirmed. This article is protected by copyright. All rights reserved.

Noninvasive diagnostic imaging for endometriosis part 1: a systematic review of recent developments in ultrasound, combination imaging, and artificial intelligence.

Endometriosis affects 1 in 9 women and those assigned female at birth. However, it takes 6.4 years to diagnose using the conventional standard of laparoscopy. Noninvasive imaging enables a timelier diagnosis, reducing diagnostic delay as well as the risk and expense of surgery. This review updates the exponentially increasing literature exploring the diagnostic value of endometriosis specialist transvaginal ultrasound (eTVUS), combinations of eTVUS and specialist magnetic resonance imaging, and artificial intelligence. Concentrating on literature that emerged after the publication of the IDEA consensus in 2016, we identified 6192 publications and reviewed 49 studies focused on diagnosing endometriosis using emerging imaging techniques. The diagnostic performance of eTVUS continues to improve but there are still limitations. eTVUS reliably detects ovarian endometriomas, shows high specificity for deep endometriosis and should be considered diagnostic. However, a negative scan cannot preclude endometriosis as eTVUS shows moderate sensitivity scores for deep endometriosis, with the sonographic evaluation of superficial endometriosis still in its infancy. The fast-growing area of artificial intelligence in endometriosis detection is still evolving, but shows great promise, particularly in the area of combined multimodal techniques. We finalize our commentary by exploring the implications of practice change for surgeons, sonographers, radiologists, and fertility specialists. Direct benefits for endometriosis patients include reduced diagnostic delay, better access to targeted therapeutics, higher quality operative procedures, and improved fertility treatment plans.

Addendum to the consensus opinion from the International Deep Endometriosis Analysis (IDEA) group: sonographic evaluation of the parametrium.

Preoperative sonographic staging in patients with suspected parametrial endometriosis is essential to plan the surgical intervention and to anticipate the need for a multidisciplinary approach, and hence optimize surgical outcome. The results of a recent metanalysis suggest that defining more accurately the ultrasonographic criteria of parametrial involvement in endometriosis is needed. The aim of this addendum to the IDEA-consensus is to highlight the sonographic characteristics of the parametrium and identify ultrasound techniques to diagnose deep endometriosis in this area. This article is protected by copyright. All rights reserved.

Diagnostic accuracy of transvaginal ultrasound for detection of endometriosis using International Deep Endometriosis Analysis (IDEA) approach: prospective international pilot study.

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in predicting deep endometriosis (DE) following the International Deep Endometriosis Analysis (IDEA) consensus methodology. METHODS: This was an international multicenter prospective diagnostic accuracy study involving eight centers across six countries (August 2018-November 2019). Consecutive participants with endometriosis suspected based on clinical symptoms or historical diagnosis of endometriosis were included. The index test was TVS performed preoperatively in accordance with the IDEA consensus statement. At each center, the index test was interpreted by a single sonologist. Reference standards were: (1) direct visualization of endometriosis at laparoscopy, as determined by a non-blinded surgeon with expertise in endometriosis surgery; and (2) histological assessment of biopsied/excised tissue. Surgery was performed within 12 months following the index TVS. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios (LR+ and LR-) of TVS in the diagnosis of DE were calculated. RESULTS: Included in the study were 273 participants with complete clinical, TVS, laparoscopic and histological data. Of these, based on histology, 256 (93.8%) were confirmed to have endometriosis, including superficial endometriosis, and 190 (69.6%) were confirmed to have DE. Based on surgical visualization, 207/273 (75.8%) patients had DE. For DE overall, the diagnostic performance of TVS based on surgical visualization as the reference standard was as follows: accuracy, 86.1%; sensitivity, 88.4%; specificity, 78.8%; PPV, 92.9%; NPV, 68.4%; LR+, 4.17; LR-, 0.15, and the diagnostic performance of TVS based on histology as the reference standard was as follows: accuracy, 85.9%; sensitivity, 89.8%; specificity, 75.9%; PPV, 90.4%; NPV, 74.6%; LR+, 3.72; LR-, 0.13. CONCLUSIONS: Using the IDEA consensus methodology provides strong diagnostic accuracy for TVS assessment of DE. We found a higher TVS detection rate of DE overall than that reported by the most recent meta-analysis on the topic (sensitivity, 79%), albeit with a lower specificity. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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

OBJECTIVE: To compare the preoperative detection of endometriosis using transvaginal sonography (TVS) supplemented by transabdominal sonography (TAS) with surgical assessment of disease, using the #Enzian classification for endometriosis. METHODS: This was a prospective multicenter diagnostic accuracy study of women undergoing TVS/TAS and radical surgery for deep endometriosis (DE) at different tertiary referral centers. The localization and grade of severity of the endometriotic lesions and adhesions were described according to the criteria of the #Enzian classification, both at preoperative ultrasound examination and during surgery. According to the #Enzian classification, the small pelvis is divided into three compartments for DE: A (rectovaginal septum and vagina); B (uterosacral and cardinal ligaments, parametrium and pelvic sidewalls); and C (rectum). In addition, further locations (F) are classified as adenomyosis (FA), urinary bladder involvement (FB) and ureteric involvement with signs of obstruction (FU). Other intestinal locations (FI) and other extragenital locations (FO) are also included. Ovarian endometriosis and adhesions at the level of the tubo-ovarian unit are listed as O and T, respectively. The #Enzian grade of severity (Grade 1-3) was determined for #Enzian compartments O, T, A, B and C based on the size of the lesion or the severity of the adhesions. Concordance between preoperative assessment using TVS/TAS and evaluation at surgery was assessed. The sensitivity, specificity, positive and negative predictive values and accuracy of TVS/TAS in the detection of endometriotic lesions/adhesions in the different #Enzian compartments were calculated. RESULTS: In total, 745 women were included in the analysis. Preoperative TVS/TAS and surgical findings showed a concordance rate ranging between 86% and 99% for the presence or absence of endometriotic lesions/adhesions, depending on the evaluated #Enzian compartment. The concordance rate between TVS and surgery ranged between 71% and 92% for different severity grades, in #Enzian compartments O, T, A, B and C. Determining the presence or absence of adhesions at the level of the tubo-ovarian unit and classifying them accurately as Grade 1, 2 or 3 on TVS was more difficult than determining the presence and severity of endometriotic lesions in #Enzian compartments O, A, B and C. The sensitivity of TVS/TAS for the detection of endometriotic lesions ranged from 50% (#Enzian compartment FI) to 95% (#Enzian compartment A), specificity from 86% (#Enzian compartment Tleft ) to 99% (#Enzian compartment FI) and 100% (#Enzian compartments FB, FU and FO), positive predictive value from 90% (#Enzian compartment Tright ) to 100% (#Enzian compartment FO), negative predictive value from 74% (#Enzian compartment Bleft ) to 99% (#Enzian compartments FB and FU) and accuracy from 88% (#Enzian compartment Bright ) to 99% (#Enzian compartment FB). CONCLUSIONS: The localization and severity of endometriotic lesions/adhesions, as described and classified according to the #Enzian classification, can be diagnosed accurately and non-invasively using TVS/TAS. The #Enzian classification provides a uniform classification system for describing endometriotic lesions, which can be used both at TVS/TAS and during surgical evaluation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of uterosacral ligaments/torus uterinus, rectovaginal septum and vaginal deep endometriosis.

STUDY QUESTION: Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis? SUMMARY ANSWER: The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent. WHAT IS KNOWN ALREADY: The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis. STUDY DESIGN SIZE DURATION: A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology. PARTICIPANTS/MATERIALS SETTING METHODS: All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants. MAIN RESULTS AND THE ROLE OF CHANCE: There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32-82%) and 95% (95% CI 90-98%), respectively, and for all MRI techniques were 81% (95% CI 66-90%) and 83% (95% CI 62-94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30-80%) and 100% (95% CI 92-100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29-74%) and 98% (95% CI 95-99%), respectively, and for all MRI techniques were 64% (95% CI 40-83%) and 98% (96% CI 93-99%). Pooled analyses were not possible for other imaging modalities. LIMITATIONS REASONS FOR CAUTION: There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease. WIDER IMPLICATIONS OF THE FINDINGS: MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies. STUDY FUNDING/COMPETING INTERESTS: No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women's and Children's Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics. REGISTRATION NUMBER: Prospective registration with PROSPERO (CRD42017059872) was obtained.

Assessing the knowledge of endometriosis diagnostic tools in a large, international lay population: an online survey.

OBJECTIVE: To assess the general population's knowledge regarding the utility and availability of tools to diagnosis endometriosis, with a focus on ultrasound. DESIGN: An international cross-sectional online survey study was performed between August and October 2019. SETTING AND POPULATION: 5301 respondents, representing 73 countries. METHODS: In all, 23 questions survey focused on knowledge of endometriosis diagnosis distributed globally via patient- and community-endometriosis groups using social media. MAIN OUTCOMES AND MEASURES: Descriptive data of the knowledge of diagnostic tools for diagnosing endometriosis, including details about diagnosis using ultrasound. RESULTS: In all, 84.0% of respondents had been previously diagnosed with endometriosis, 71.5% of whom had been diagnosed at the time of surgery. Ultrasound and MRI were the methods of diagnosis in 6.5% and 1.8%, respectively. A total of 91.8%, 28.8% and 16.6% of respondents believed surgery, ultrasound and MRI could diagnose endometriosis, respectively (more than one answer allowed). In those diagnosed by surgery, 21.7% knew about ultrasound as a diagnosis method, whereas in those diagnosed non-surgically, 51.5% knew (P < 0.001). In all, 14.7%, 31.1% and 18.2% stated superficial, ovarian and deep endometriosis could be diagnosed with ultrasound (32.9% stated they did not know which phenotypes of endometriosis could be diagnosed). Lastly, 58.4% of respondents do not believe they could access an advanced ultrasound in their region. CONCLUSIONS: There is a limited appreciation for the role of non-surgical diagnostic tests for endometriosis among lay respondents to this survey. TWEETABLE ABSTRACT: International survey shows limited awareness of lay respondents about non-surgical endometriosis diagnostic tools.

Transvaginal sonography determines accurately extent of infiltration of rectosigmoid deep endometriosis.

OBJECTIVE: To investigate the agreement of measurements of the three diameters of rectosigmoid deep endometriosis (DE) lesions between presurgical evaluation using transvaginal sonography (TVS) and postsurgical specimen measurement (PSM). METHODS: This was a prospective observational multicenter study including symptomatic women undergoing surgical treatment for DE involving the rectosigmoid, by either discoid or segmental resection, from April 2017 to December 2019. TVS was performed presurgically to evaluate lesion size (craniocaudal-midsagittal length, anteroposterior thickness and transverse diameter), in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement, and was compared with PSM. The agreement of lesion dimensions between the two methods was assessed by Bland-Altman plots and limits of agreement and additionally by the intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. Systematic and proportional bias was assessed using the paired t-test. RESULTS: A total of 207 consecutive women were eligible for inclusion. Forty-one women were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid resections were performed (both procedures were performed in three women). The mean difference between TVS and PSM was 0.90 (95% CI, 0.85-0.95) mm for lesion length measurements, 1.03 (95% CI, 0.98-1.09) mm for lesion thickness measurements and 0.84 (95% CI, 0.79-0.89) mm for transverse diameter measurements. Bland-Altman analysis demonstrated good agreement between the two methods for measurements of lesion length. Furthermore, there was good reliability and correlation between TVS and PSM for lesion length measurements, as demonstrated by an ICC of 0.82 (95% CI, 0.75-0.87) and Pearson's correlation coefficient of 0.72 (95% CI, 0.62-0.80), moderate-to-good reliability and correlation for lesion thickness measurements, with an ICC of 0.76 (95% CI, 0.67-0.82) and Pearson's correlation coefficient of 0.61 (95% CI, 0.51-0.70), and poor-to-moderate reliability and correlation for transverse diameter measurements, with an ICC of 0.58 (95% CI, 0.39-0.71) and Pearson's correlation coefficient of 0.46 (95% CI, 0.33-0.58). CONCLUSION: Preoperative TVS determines accurately rectosigmoid DE lesion length. TVS can thereby contribute to optimal planning of surgical treatment options in women with rectosigmoid DE. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis.

OBJECTIVE: To review the diagnostic accuracy and determine the optimum imaging modality for the detection of bladder deep endometriosis (DE) in women with a clinical suspicion of endometriosis. METHODS: A systematic review of studies published from inception to May 2020 using Embase, Google Scholar, Medline, PubMed and Scopus. Prospective studies, which pre-operatively assessed any imaging modality for the presence of bladder DE, and correlated with the gold standard surgical data as a reference were included. The QUADAS-2 tool was used to assess quality. This review was prospectively registered with PROSPERO (CRD42017059872). RESULTS: Of the 1,977 references identified, 8 studies (n = 1,052) were included in the analysis. The overall pooled sensitivity and specificity, from which the likelihood ratio of a positive test (LR+), likelihood ratio of a negative test (LR-) and diagnostic odds ratio (DOR) were calculated, for all transvaginal ultrasonography (TVS) techniques were 55 % (95 % CI 28-79%), 99 % (95 % CI 98-100%), 54.5 (95 % CI 18.9-157.4), 0.46 (95 % CI 0.25 - 0.85) and 119 (95 % CI 24-577), and for only two-dimensional (2D) TVS 53 % (95 % CI 23-82%), 99 % (96 % CI 97-100%), 48.8 (95 % CI 13.1-181.4), 0.47 (95 % CI 0.23 - 0.98), and 104 (95 % CI 15-711), respectively. Meta-analyses of the other modalities, namely magnetic resonance imaging (MRI) and transrectal endoscopic sonography (RES), were not possible due to the limited number of studies. There was significant heterogeneity and the studies were considered poor methodologically according to the QUADAS-2 tool. CONCLUSIONS: Whilst the sensitivity of TVS was limited, the specificity was excellent. Given that there is a paucity of literature for other imaging modalities, until more studies are performed, TVS should be considered as the first-line tool given it is the only modality with sufficient evidence.

What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis.

BACKGROUND: Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging). OBJECTIVES: To highlight the advantages and disadvantages of the three classification systems. METHODS: This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis. CONCLUSIONS: A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.

Optimal imaging modality for detection of rectosigmoid deep endometriosis: systematic review and meta-analysis.

OBJECTIVES: To review the accuracy of different imaging modalities for the detection of rectosigmoid deep endometriosis (DE) in women with clinical suspicion of endometriosis, and to determine the optimal modality. METHODS: A search was conducted using PubMed, MEDLINE, Scopus, EMBASE and Google Scholar to identify studies using imaging to evaluate women with suspected DE, published from inception to May 2020. Studies were considered eligible if they were prospective and used any imaging modality to assess preoperatively for the presence of DE in the rectum/rectosigmoid, which was then correlated with the surgical diagnosis as the reference standard. Eligibility was restricted to studies including at least 10 affected and 10 unaffected women. The QUADAS-2 tool was used to assess the quality of the included studies. Mixed-effects diagnostic meta-analysis was used to determine the overall pooled sensitivity and specificity of each imaging modality for rectal/rectosigmoid DE, which were used to calculate the likelihood ratio of a positive (LR+) and negative (LR-) test and diagnostic odds ratio (DOR). RESULTS: Of the 1979 records identified, 30 studies (3374 women) were included in the analysis. The overall pooled sensitivity and specificity, LR+, LR- and DOR for the detection of rectal/rectosigmoid DE using transvaginal sonography (TVS) were, respectively, 89% (95% CI, 83-92%), 97% (95% CI, 95-98%), 30.8 (95% CI, 17.6-54.1), 0.12 (95% CI, 0.08-0.17) and 264 (95% CI, 113-614). For magnetic resonance imaging (MRI), the respective values were 86% (95% CI, 79-91%), 96% (95% CI, 94-97%), 21.0 (95% CI, 13.4-33.1), 0.15 (95% CI, 0.09-0.23) and 144 (95% CI, 70-297). For computed tomography, the respective values were 93% (95% CI, 84-97%), 95% (95% CI, 81-99%), 20.3 (95% CI, 4.3-94.9), 0.07 (95% CI, 0.03-0.19) and 280 (95% CI, 28-2826). For rectal endoscopic sonography (RES), the respective values were 92% (95% CI, 87-95%), 98% (95% CI, 96-99%), 37.1 (95% CI, 21.1-65.4), 0.08 (95% CI, 0.05-0.14) and 455 (95% CI, 196-1054). There was significant heterogeneity and the studies were considered methodologically poor according to the QUADAS-2 tool. CONCLUSIONS: The sensitivity of TVS for the detection of rectal/rectosigmoid DE seems to be slightly better than that of MRI, although RES was superior to both. The specificity of both TVS and MRI was excellent. As TVS is simpler, faster and more readily available than the other methods, we believe that it should be the first-line diagnostic tool for women with suspected DE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis.

STUDY QUESTION: Is expectant management (EM) of tubal ectopic pregnancy (EP) an effective and safe treatment strategy when compared to alternative interventions? SUMMARY ANSWER: There is insufficient evidence to conclude EM yields a difference in the resolution of tubal EP, the avoidance of surgery or time to resolution of tubal EP when compared to intramuscular methotrexate in stable patients with ß-hCG <1500 IU/l. WHAT IS ALREADY KNOWN: The utilisation of medical and surgical management for EP is well established. EM aims to allow spontaneous resolution of the EP without intervention. STUDY DESIGN SIZE AND DURATION: We performed a systematic review and meta-analysis, searching Ovid MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, OpenGrey.eu, Google Scholar, cross-referencing citations and trial registries to 15 December 2019. There were no limitations placed on language or publication date. Search terms included tubal EP and EM as well as variations of these terms. PARTICIPANTS/MATERIALS SETTING AND METHOD: We considered studies that included patients with tubal EP, EM as a comparator, and that were randomised controlled trials (RCTs). The primary outcome was resolution of tubal EP. Secondary outcomes included avoidance of surgery and the time to resolution of EP. Two reviewers independently selected the studies, assessed bias and extracted data. Relative risk (RR) and mean difference with 95% CI were assessed using a random effects model. The certainty of evidence was scored according to Grading of Recommendations Assessment, Development and Evaluation guidelines. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 920 studies were screened. Five studies were eligible for inclusion in the systematic review. Two RCTs comparing methotrexate to EM were identified as being eligible for inclusion in meta-analysis. No RCTs comparing surgery to EM were identified. Compared with EM, there was insufficient evidence that methotrexate yields a difference on resolution of tubal EP (RR 1.04, 95% CI 0.88-1.23, P = 0.67; two RCTs, moderate-certainty evidence), avoiding surgery (RR 1.10, 95% CI 0.94-1.29, P = 0.25; two RCTs, low-certainty evidence) or the time to resolution of tubal EP (-2.56 days (favouring EM), 95% CI -7.93-2.80, P = 0.35; two RCTs, low-certainty evidence). LIMITATIONS REASONS FOR CAUTION: Only two RCTs with a total of 103 patients were eligible for inclusion in this meta-analysis. Further RCTs comparing EM to medical and surgical management are needed and these should also report adverse events. Patient preference should also be evaluated. WIDER IMPLICATIONS OF THE FINDINGS: We found insufficient evidence of differences in terms of resolution, avoidance of surgery and time to resolution between expectant and medical management. Given the imprecision in the effect estimates as demonstrated by the wide CIs, resulting in the downgrading of certainty of evidence for all outcomes in this meta-analysis, larger RCTs comparing interventions for tubal EP are needed. Caution should be exercised when trying to decide between EM and methotrexate to treat tubal EP. STUDY FUNDING/COMPETING INTERESTS: There was no funding for this study. NICM receives funding from various sources; none specifically supported this research. M.L. reports grants from Australian Women and Children's Research Foundation, outside the submitted work. M.A.: As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. This systematic review was not specifically supported by donor or sponsor funding to NICM. M.A. reports a partnership grant with Metagenetics outside the submitted work. G.C. reports grants from Australian Women and Children's Research Foundation, personal fees from Roche and GE Healthcare, outside the submitted work. The remaining authors report no conflicts of interest. PROSPERO REGISTRATION NUMBER: CRD42020142736.

SonoPODography: A new diagnostic technique for visualizing superficial endometriosis.

OBJECTIVE: To perform a pilot diagnostic accuracy study of a novel transvaginal ultrasonography procedure called saline-infusion sonoPODography to predict superficial endometriosis in patients with suspected endometriosis. STUDY DESIGN: A prospective single-center diagnostic accuracy study was performed from September 2019-November 2019. The index test sonoPODography was performed and the results were documented in a standardized fashion. SonoPODography was performed by installing saline into the pouch of Douglas (POD) via an intrauterine balloon catheter to create an acoustic window between the ultrasound probe and surrounding structures. The pelvis was then assessed for the presence or absence of superficial endometriosis using pre-defined features. Direct visualization at laparoscopy and histological assessment of excised endometriosis confirmed the outcome. The diagnostic performance of sonoPODography was evaluated. RESULTS: 42 consecutive participants underwent sonoPODography. Superficial endometriosis was identified by sonoPODography in 24/42 (57.1 %) and in 37/42 (88.1 %) participants by direct visualization at laparoscopy. The overall diagnostic performance of sonoPODography was: accuracy 69.1 %, sensitivity 64.9 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 27.8 %. Amongst those without deep endometriosis/endometriomas/pouch of Douglas obliteration, the diagnostic performance was: accuracy 80.0 %, sensitivity 77.7 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 33.3 %. The pouch of Douglas peritoneum was the most common site of superficial endometriosis. CONCLUSIONS: SonoPODography is a novel ultrasound-based procedure that permits the direct visualization of superficial with respectable diagnostic accuracy. The findings of this pilot study are promising and justify the initiation of a larger outpatient study. SonoPODography may establish new avenues for the non-invasive diagnosis and investigation of endometriosis.