Can AAGL 2021 Endometriosis Classification be Adopted at Preoperative Ultrasound for Reliably Predicting Surgical Complexity?

Abstract

<h3>Study Objective</h3> to evaluate the use of new AAGL2021 Endometriosis classification (AAGL2021-EC) for staging at ultrasound (ULS) women undergoing surgical approach for deep endometriosis (DE). <h3>Design</h3> single-center retrospective analysis of a prospectively collected database (NCT05291624). <h3>Setting</h3> referral center for endometriosis. <h3>Patients or Participants</h3> consecutive women undergoing surgical approach for DE. <h3>Interventions</h3> at preoperative ULS, the presence of endometriosis was staged by using the AAGL2021-EC (ULS score). Laparoscopic surgical approach was performed within 15 days from the ultrasonographic evaluation. During surgery, the presence of endometriosis was staged by using the AAGL2021-EC (surgical score); the surgeons were blinded to the results of the preoperative ULS staging. All the women were treated by full radical resection of all visible endometriotic lesions. <h3>Measurements and Main Results</h3> 198 patients were enrolled. The mean ULS score was significantly lower than the surgical score (24.6 ± 12.3 vs 35.9 ± 19.6; p<0.001). In 53.5% (n=106) of patients, the severity stage predicted by ULS score coincided exactly with that described at surgery; in 32.8% (n=65) cases, ULS predicted a higher surgical severity stage; in 13.7% (n=27) cases, ULS predicted a lower severity stage. There was a moderate agreement between ULS severity stage and surgical procedures performed according to the distinguished severity stages expected by the AAGL2021-EC (V=0.520; p=0.0003); in particular, the agreement was worse when predicting surgical procedures related to lower (V=0.172; p=0.327) than higher (V=0.412; p=0.005) severity stages (p<0.001). The maximum percentages of exact concordances between ULS and surgical specific localization scores were observed for bladder (83.1%) and vagina (77.2%); the minimum percentage for peritoneum (41.2%). The most relevant underestimation and overestimation in specific localization scores were reported, respectively, for left ureter (46.5%) and right ovary (31.5%). <h3>Conclusion</h3> the ultrasonographic use of AAGL2021-EC moderately predicts surgical complexity; in particular, it tends to be worse when predicting easier surgical procedures expected by AAGL2021-EC severity stages.