Abstract
Objectives The primary aim was to investigate the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the mapping of deep pelvic endometriosis (DE) in a diseased population. The secondary aim was to offer first insights into the clinical applicability of the new International Deep Endometriosis Analysis group (IDEA) consensus for sonographic evaluation, which was also adapted for MRI and surgical reporting in this study. Methods The study was a prospective observational cohort study. In this study, consecutive women planned for surgical treatment for DE underwent preoperative mapping of pelvic disease using TVS and MRI (index tests). The results were compared against the intraoperative findings with histopathological confirmation (reference standard). In case of disagreement between intraoperative and pathology findings, the latter was prioritised. Index tests and surgical findings were reported using a standardised protocol based on the IDEA consensus. Results The study ran from 07/2016 to 02/2018. One-hundred and eleven women were approached, but 60 declined participation. Out of the 51 initially recruited women, two were excluded due to the missing reference standard. Both methods (TVS and MRI) had the same sensitivity and specificity in the detection of DE in the upper rectum (UpR) and rectosigmoid (RS) (UpR TVS and MRI sensitivity and specificity 100%; RS TVS and MRI sensitivity 94%; TVS and MRI specificity 84%). In the assessment of DE in the bladder (Bl), uterosacral ligaments (USL), vagina (V), rectovaginal septum (RVS), and overall pelvis (P), TVS had marginally higher specificity but lower sensitivity than MRI (Bl TVS sensitivity 89%, specificity 100%, MRI sensitivity 100%, specificity 95%; USL TVS sensitivity 74%, specificity 67%, MRI sensitivity 94%, specificity 60%; V TVS sensitivity 55%, specificity 100%, MRI sensitivity 73%, specificity 95%; RVS TVS sensitivity 67%, specificity 100%, MRI sensitivity 83%, specificity 93%; P TVS sensitivity 78%, specificity 97%, MRI sensitivity 91%, specificity 91%). No significant differences in diagnostic accuracy between TVS and MRI were observed except USL assessment (p=0.04) where MRI was significantly better and pouch of Douglas obliteration (p=0.04) where MRI was significantly better and pouch of Douglas obliteration (κ) = 0.727 [p=0.04) where MRI was significantly better and pouch of Douglas obliteration (κ) = 0.727 [p=0.04) where MRI was significantly better and pouch of Douglas obliteration (p=0.04) where MRI was significantly better and pouch of Douglas obliteration (Conclusion We found that both imaging techniques had overall good agreement with the reference standard in the detection of deep pelvic endometriosis. This is the first study to date involving the IDEA consensus for ultrasound, its modified version for MRI, and intraoperative reporting of deep pelvic endometriosis in clinical practice.
Highlights
Endometriosis has been recognized for decades as the leading cause of pelvic pain in women of reproductive age [1]
Ultrasound and magnetic resonance imaging (MRI) performances were not statistically different except in the assessment of pouch of Douglas (POD) obliteration where Transvaginal ultrasound (TVS) was superior to MRI (p 0.040) and in the uterosacral ligaments (USLs) where MRI was better in detecting deep endometriosis (DE) in the USL in general (p 0.039). e difference in the detection of DE in USL was only present on the right side (p 0.001) with the left side showing no difference (p 0.220)
Our primary aim was to assess the diagnostic accuracy of TVS and MRI in preoperative pelvic DE mapping on the same cohort, using one standardised protocol for index tests and reference standard
Summary
Endometriosis has been recognized for decades as the leading cause of pelvic pain in women of reproductive age [1]. Cornille et al defined deep endometriosis (DE) as infiltration of the tissue deeper than 5 mm with a typical location in the wall of bladder and bowel, uterosacral ligaments (USL), vagina, and rectovaginal septum (RVS) [2]. In the most recent meta-analysis of these methods by Guerriero et al, both showed similar performance when assessing DE in the rectosigmoid, uterosacral ligaments, and rectovaginal septum [3]. Studies comparing TVS and MRI in the assessment of bladder DE are scarce, and the best available evidence for TVS shows sensitivity 62% and specificity 100% [4], which was similar to MRI performance noted in a different systematic review (sensitivity 64%, specificity 98%) [5]. Ultrasound could be more useful in identifying pelvic DE compared with MRI, but none of the imaging methods could be suggested to replace surgical staging of overall pelvic endometriosis
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