Classification Of Endometriosis Research Articles

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.

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

Horizons in Endometriosis: Proceedings of the Montreux Reproductive Summit, 14-15 July 2023.

Endometriosis is a complex and chronic gynaecological disorder that affects millions of women worldwide, leading to significant morbidity and impacting reproductive health. This condition affects up to 10% of women of reproductive age and is characterised by the presence of endometrial-like tissue outside the uterus, potentially leading to symptoms such as chronic pelvic pain, dysmenorrhoea, dyspareunia, and infertility. The Montreux summit brought a number of experts in this field together to provide a platform for discussion and exchange of ideas. These proceedings summarise the six main topics that were discussed at this summit to shed light on future directions of endometriosis classification, diagnosis, and therapeutical management. The first question addressed the possibility of preventing endometriosis in the future by identifying risk factors, genetic predispositions, and further understanding of the pathophysiology of the condition to develop targeted interventions. The clinical presentation of endometriosis is varied, and the correlation between symptoms severity and disease extent is unclear. While there is currently no universally accepted optimal classification system for endometriosis, several attempts striving towards its optimisation - each with its own advantages and limitations - were discussed. The ideal classification should be able to reconcile disease status based on the various diagnostic tools, and prognosis to guide proper patient tailored management. Regarding diagnosis, we focused on future tools and critically discussed emerging approaches aimed at reducing diagnostic delay. Preserving fertility in endometriosis patients was another debatable aspect of management that was reviewed. Moreover, besides current treatment modalities, potential novel medical therapies that can target underlying mechanisms, provide effective symptom relief, and minimise side effects in endometriotic patients were considered, including hormonal therapies, immunomodulation, and regenerative medicine. Finally, the question of hormonal substitution therapy after radical treatment for endometriosis was debated, weighing the benefits of hormone replacement.

Disrupted Tuzzerella abundance and impaired l-glutamine levels induce Treg accumulation in ovarian endometriosis: a comprehensive multi-omics analysis

IntroductionThe microbial community plays a crucial role in the pathological microenvironment. However, the structure of the microbial community within endometriotic lesions and its impact on the microenvironment is still limited.MethodsAll 55 tissue samples, including ovarian ectopic (OEMs) and normal (NE) endometrium, were subjected to 16S rRNA sequencing, metabolomic and proteomic analysis.ResultsWe found the abundance of Tuzzerella is significantly lower in OEMs compared to NE tissue (p < 0.01). We selected samples from these two groups that exhibited the most pronounced difference in Tuzzerella abundance for further metabolomic and proteomic analysis. Our findings indicated that endometriotic lesions were associated with a decrease in l-Glutamine levels. However, proteomic analysis revealed a significant upregulation of proteins related to the complement pathway, including C3, C7, C1S, CLU, and A2M. Subsequent metabolic and protein correlation predictions demonstrated a negative regulation between l-Glutamine and C7. In vitro experiments further confirmed that high concentrations of Glutamine significantly inhibit C7 protein expression. Additionally, immune cell infiltration analysis, multiplex immunofluorescence, and multifactorial testing demonstrated a positive correlation between C7 expression and the infiltration of regulatory T cells (Tregs) in ectopic lesions, while l-Glutamine was found to negatively regulate the expression of chemotactic factors for Tregs.ConclusionIn this study, we found a clear multi-omics pathway alteration, “Tuzzerella (microbe)—l-Glutamine (metabolite)—C7 (protein),” which affects the infiltration of Tregs in endometriotic lesions. Our findings provide insights into endometriosis classification and personalized treatment strategies based on microbial structures.Graphical abstract

Discrepancies in staging and perioperative classification of pelvic endometriosis according to #Enzian 2021.

The aim of this study is to compare the extent of ovarian endometriosis diagnosed at preoperative staging with subsequent perioperative findings. Definition of discrepancies observed according to the #Enzian 2021 classification. The cohort includes 62 patients of reproductive age with preoperative findings of ovarian endometrioma. Patients were divided according to the #Enzian 2021 classification into subgroups (O1, O2 + O3) with unilateral and bilateral findings. The percentage concordance of preoperative and perioperative findings was evaluated. In the evaluation of ovarian involvement, the preoperative ultrasound diagnosis shows almost 100% agreement with the findings on the ovaries during surgery. Periadnexal adhesions were predicted preoperatively in only half of the cases. The difference in laterality was confirmed with T3 involvement in the O2 + O3 subgroup. In the bilateral involvement, the finding of the presence of grade 3 adhesions was doubled. An association of ovarian form of endometriosis (O2-O3) with deep infiltrating endometriosis of the small pelvis was observed in 50% of the cohort. The ovarian form of endometriosis is associated with the occurrence of other endometriosis lesions in the small pelvis. In this study, it was confirmed that preoperative staging underestimates the extent of endometriosis in the small pelvis. In the surgical management of ovarian endometriosis, extensive adhesive process should be expected.

Assessment of a Digital Symptom Checker Tool's Accuracy in Suggesting Reproductive Health Conditions: Clinical Vignettes Study.

Reproductive health conditions such as endometriosis, uterine fibroids, and polycystic ovary syndrome (PCOS) affect a large proportion of women and people who menstruate worldwide. Prevalence estimates for these conditions range from 5% to 40% of women of reproductive age. Long diagnostic delays, up to 12 years, are common and contribute to health complications and increased health care costs. Symptom checker apps provide users with information and tools to better understand their symptoms and thus have the potential to reduce the time to diagnosis for reproductive health conditions. This study aimed to evaluate the agreement between clinicians and 3 symptom checkers (developed by Flo Health UK Limited) in assessing symptoms of endometriosis, uterine fibroids, and PCOS using vignettes. We also aimed to present a robust example of vignette case creation, review, and classification in the context of predeployment testing and validation of digital health symptom checker tools. Independent general practitioners were recruited to create clinical case vignettes of simulated users for the purpose of testing each condition symptom checker; vignettes created for each condition contained a mixture of condition-positive and condition-negative outcomes. A second panel of general practitioners then reviewed, approved, and modified (if necessary) each vignette. A third group of general practitioners reviewed each vignette case and designated a final classification. Vignettes were then entered into the symptom checkers by a fourth, different group of general practitioners. The outcomes of each symptom checker were then compared with the final classification of each vignette to produce accuracy metrics including percent agreement, sensitivity, specificity, positive predictive value, and negative predictive value. A total of 24 cases were created per condition. Overall, exact matches between the vignette general practitioner classification and the symptom checker outcome were 83% (n=20) for endometriosis, 83% (n=20) for uterine fibroids, and 88% (n=21) for PCOS. For each symptom checker, sensitivity was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, and 100% for PCOS; specificity was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 75% for PCOS; positive predictive value was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, 80% for PCOS; and negative predictive value was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 100% for PCOS. The single-condition symptom checkers have high levels of agreement with general practitioner classification for endometriosis, uterine fibroids, and PCOS. Given long delays in diagnosis for many reproductive health conditions, which lead to increased medical costs and potential health complications for individuals and health care providers, innovative health apps and symptom checkers hold the potential to improve care pathways.

#390 : Why Our Clinical Pregnancy Rates Have Improved Over the Past Two Years: Exploring Key Points of Gonadotropin-Releasing Hormone Antagonist Protocol in Fresh Embryo Transfer Cycles

Background and Aims: GnRH-ant protocol is effective in preventing a surge of pituitary luteinising hormone during controlled ovarian stimulation. In recent years, GnRH-ant protocol has been optimised to improve in vitro fertilisation outcomes. However, firstly, the success rate of frozen embryo transfer is consistently better than that of fresh embryo transfer and secondly, the success rate of GnRH-ant protocol on fresh embryo transfer is lower than that of the long protocol. This study aims to draw out a comparison of before and after data from our own centre to find the reasons for the gradual maturation of GnRH-ant protocol on fresh embryo transfer. Our study proposed to investigate the determinants affecting fresh embryo transfer in gonadotropin-releasing hormone antagonist (GnRH-ant) protocols. Method: We reviewed 2464 fresh embryo transfer cycles for IVF/ICSI-ET assisted reproduction techniques performed at our centre from 1 January 2015 to 31 December 2019. The exclusion criteria were as follows: endometriosis grade III to IV (American Fertility Society classification of endometriosis); adenomyosis; severe male oligospermia or obstructive azoospermia. Firstly, we compared the single-cycle clinical pregnancy rates between 2015 to 2017 and 2018 to 2019. Next, we performed a multifactorial regression analysis to understand what changes our centre had made between the five years in terms of years. Finally, data from 2015 to 2019 were grouped as a whole and then subjected to understand exactly where the differences in clinical pregnancy rates were affecting the GnRH-ant protocol for fresh embryo transfer. Results: A total of 1,388 cycles were included from 2015 to 2017, with a clinical pregnancy rate of 51.42% (688/1388). 1,076 cycles were included from 2018 to 2019, with a clinical pregnancy rate of 57.43% (618/1076). 2018 to 2019 compared to 2015 to 2017 for first-time IVF/ICSI. There was a 6.01% increase in clinical pregnancy rate for women who had assisted conception and performed GnRH-ant protocol with fresh embryo transfer. The results of the univariate analysis conducted suggested that the factors influencing the classification of clinical pregnancy included female basal E2 base, LH base, FSH base, P base, female Gn initiation date E2 start, LH start, FSH start, P start, Gn initiation volume and number of Gn days, antagonist addition date E2 add, LH add, FSH add, P add, plate machine day E2 trigger, LH trigger, P trigger, plate machine day number of different follicles in the meridian follicles 10-14 mm, follicles 14-16 mm, follicles 16-18 mm, follicles 18mm or more. Multifactorial regression analysis after correction suggested that age, BMI, endometrial thickness on the day of transfer, number of embryos transferred and progesterone level on HCG Day were independent influencing factors for successful pregnancy with antagonist regimen and fresh embryo transfer. Conclusion: Age, BMI, endometrial thickness on the day of transfer, number of embryos transferred and progesterone levels on HCG Day were independent influences.

Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement.

The purpose of this investigation was to evaluate the inter- and intraobserver variability of the updated #Enzian classification of endometriosis on MRI and to evaluate the influence of reader experience on interobserver concordance. This was a prospective single-center study. All patients were included who received an MRI of the pelvis for evaluation of endometriosis between March and July 2023 and who have provided written informed consent. Images were reviewed independently for endometriosis by three radiologists, utilizing the MRI-applicable categories of the #Enzian classification. Two radiologists had experience in pelvic MRI and endometriosis imaging. One radiologist had no specific experience in pelvic MRI and received a one-hour briefing beforehand. Fifty consecutive patients (mean age, 34.9 years ±8.6 [standard deviation]) were prospectively evaluated. Interobserver agreement was excellent for diagnosis of deep infiltrating endometriosis (Fleiss' kappa: 0.89; 95% CI 0.73-1.00; p < 0.001) and endometriomas (Fleiss' kappa: 0.93; 95% CI 0.77-1.00; p < 0.001). For the experienced readers, interobserver agreement in the assessment of compartments A, B and C was excellent (κw ranging from 0.84; 95% CI 0.71-0.97; p < 0.001 to 0.89; 95% CI 0.82-0.97; p < 0.001). For the pairings of the experienced readers to the reader without specific experience in pelvic MRI, agreement was substantial to excellent (κw ranging from 0.64; 95% CI 0.44-0.85; p < 0.001 to 0.91; 95% CI 0.84-0.98; p < 0.001). Intraobserver variability was excellent for compartments A, B and C (κw ranging from 0.85; 95% CI 0.73-0.96; p < 0.001 to 0.95; 95% CI 0.89-1.00; p < 0.001). With sufficient experience, the #Enzian classification enables the achievement of excellent inter- and intraobserver agreement in MRI-based diagnosis of deep infiltrating endometriosis and endometriomas.

10461 Feasibility and Inter-Reader Reliability of the 2021 Endometriosis Classification System Among Pre-Operative MRIs

10461 Feasibility and Inter-Reader Reliability of the 2021 Endometriosis Classification System Among Pre-Operative MRIs

Distribution of smooth muscle actin and collagen in superficial peritoneal endometriotic lesions varies from the surrounding microenvironment

Research questionDo different subtypes of superficial peritoneal endometriotic lesions exist, based on the presence and morphology of smooth muscle, collagen fibres and immune cell populations? DesignA retrospective cohort study of 24 patients, from across the menstrual cycle, with surgically and histologically confirmed endometriosis. Immunofluorescence was used to delineate the CD10 stromal area of lesions (n = 271 lesions from 67 endometriotic biopsies), and then smooth muscle actin (SMA) positive tissue and immune cell populations (CD45+ and CD68+) were quantified within and adjacent to these lesions. Second harmonic generation microscopy was used to evaluate the presence and morphology of type-1 collagen fibres within and surrounding lesions. ResultsOverall, immune cell numbers and the area of SMA and collagen within endometriotic lesions tended to be low, but a spectrum of presentations significantly varied, particularly in the adjacent tissue microenvironment, based on lesion locations, the morphology of endometriotic gland profiles, or both. Lesions in which collagen fibres formed well aligned capsules around the CD10+ stromal border were identified compared with lesions in which collagen fibre distribution was random. Considerable inter- and intra-patient variability in the morphology of SMA and collagen was observed within and surrounding lesions. ConclusionThese data demonstrate considerable diversity in the presence of immune cells and morphology of SMA and collagen within, but even more so, surrounding endometriotic lesions, even within individual patients. This heterogeneity, especially within individual patients, presents a challenge to incorporating these cell and tissue types into any new endometriosis classification systems or prognostic approaches.

A Novel Classification of Endometriosis Based on Clusters of Comorbidities.

Endometriosis is a heterogeneous, complex, and still challenging disease, due to its epidemiological, etiological and pathogenic, diagnostic, therapeutic, and prognosis characteristics. The classification of endometriosis is contentious, and existing therapies show significant variability in their effectiveness. This study aims to capture and describe clusters of women with endometriosis based on their comorbidity. With data extracted from electronic records of primary care, this study performs a hierarchical clustering with the Ward method of women with endometriosis with a subsequent analysis of the distribution of comorbidities. Data were available for 4055 women with endometriosis, and six clusters of women were identified: cluster 1 (less comorbidity), cluster 2 (anxiety and musculoskeletal disorders), cluster 3 (type 1 allergy or immediate hypersensitivity); cluster 4 (multiple morbidities); cluster 5 (anemia and infertility); and cluster 6 (headache and migraine). Clustering aggregates similar units into similar clusters, partitioning dissimilar objects into other clusters at a progressively finer granularity-in this case, groups of women with similarities in their comorbidities. Clusters may provide a deeper insight into the multidimensionality of endometriosis and may represent diverse "endometriosis trajectories" which may be associated with specific molecular and biochemical mechanisms. Comorbidity-based clusters may be important to the scientific study of endometriosis, contributing to the clarification of its clinical complexity and variability. An awareness of those comorbidities may help elucidate the etiopathogenesis and facilitate the accurate earlier diagnosis and initiation of treatments targeted toward particular subgroups.

Pregnancy after laparoscopic surgery for endometriosis: How long should we wait? A retrospective study involving a long-term follow up at a university endometriosis center.

To find the factors that influence the time until pregnancy after laparoscopic intervention and to evaluate the proper time to start assisted reproductive therapy (ART). This is a retrospective analysis that includes a prospective evaluation of patients with infertility and with a diagnosis of endometriosis. A subgroup of patients who desired to be pregnant after laparoscopic intervention (102 patients) was followed up for 36-197 months after the surgery. In this study, 71 (69.9%) and 60 (58.8%) of the patients achieved pregnancy and live birth, respectively. In the group of patients who became pregnant, the duration of infertility was significantly lower (2.7 ± 2.1 years vs. 4.7 ± 3.2 years). The median time until pregnancy after laparoscopic intervention was 8 months (the average was 10 months). After 38 months, no pregnancy occurred. In the group of patients with endometriosis and infertility, the first 12 months were the optimal time for pregnancy. For women with revised American Society for Reproductive Medicine classification of endometriosis (rASRM) stages I and II, spontaneous pregnancy can probably be delayed for up to 24 months, but in patients with rASRM stages III and IV, ART may be considered after 12 months. The gynecologist must be careful about the timing of further interventions after the operation.

KRAS mutations and endometriosis burden of disease.

The clinical phenotype of somatic mutations in endometriosis is unknown. The objective was to determine whether somatic KRAS mutations were associated with greater disease burden in endometriosis (i.e. more severe subtypes and higher stage). This prospective longitudinal cohort study included 122 subjects undergoing endometriosis surgery at a tertiary referral center between 2013 and 2017, with 5-9 years of follow-up. Somatic activating KRAS codon 12 mutations were detected in endometriosis lesions using droplet digital PCR. KRAS mutation status for each subject was coded as present (KRAS mutation in at least one endometriosis sample in a subject) or absent. Standardized clinical phenotyping for each subject was carried out via linkage to a prospective registry. Primary outcome was anatomic disease burden, based on distribution of subtypes (deep infiltrating endometriosis, ovarian endometrioma, and superficial peritoneal endometriosis) and surgical staging (Stages I-IV). Secondary outcomes were markers of surgical difficulty, demographics, pain scores, and risk of re-operation. KRAS mutation presence was higher in subjects with deep infiltrating endometriosis or endometrioma lesions only (57.9%; 11/19) and subjects with mixed subtypes (60.6%; 40/66), compared with those with superficial endometriosis only (35.1%; 13/37) (p=0.04). KRAS mutation was present in 27.6% (8/29) of Stage I cases, in comparison to 65.0% (13/20) of Stage II, 63.0% (17/27) of Stage III, and 58.1% (25/43) of Stage IV cases (p=0.02). KRAS mutation was also associated with greater surgical difficulty (ureterolysis) (relative risk [RR]=1.47, 95% CI: 1.02-2.11) and non-Caucasian ethnicity (RR=0.64, 95% CI: 0.47-0.89). Pain severities did not differ based on KRAS mutation status, at either baseline or follow-up. Re-operation rates were low overall, occurring in 17.2% with KRAS mutation compared with 10.3% without (RR=1.66, 95% CI: 0.66-4.21). In conclusion, KRAS mutations were associated with greater anatomic severity of endometriosis, resulting in increased surgical difficulty. Somatic cancer-driver mutations may inform a future molecular classification of endometriosis.

Long Non-Coding RNA SNHG4 Expression in Women with Endometriosis: A Pilot Study.

Endometriosis is a chronic disease of the genital organs that mainly affects women of reproductive age. The analysis of long non-coding RNA (lncRNA) in endometriosis is a novel field of science. Recently, attention has been drawn to SNHG4, which is incorrectly expressed in various human diseases, including endometriosis. The aim of this pilot study was to analyze the expression of lncRNA small nucleolar RNA host gene 4 (SNHG4) and to investigate its significance in endometriosis. LncRNA SNHG4 expression was investigated in paraffin blocks in endometriosis patients (n = 100) and in endometriosis-free controls (n = 100) using a real-time PCR assay. This study revealed a higher expression of SNHG4 in endometriosis patients than in controls. A statistically significant relationship between expression level and SNHG4 was found in relation to The Revised American Society for Reproductive Medicine classification of endometriosis, 1996, in the group of patients with endometriosis. This pilot study has revealed that gene expression in SNHG4 plays an important role in the pathogenesis of endometriosis.

Спорные вопросы неинвазивной диагностики малых форм эндометриоза

Objective of the Review: To discuss the significance and possibility of non–invasive diagnosis of small forms of endometriosis, consider the features, advantages and disadvantages of transvaginal ultrasound (TV–ultrasound) and magnetic resonance imaging (MRI). Key points. Endometriosis in women of reproductive age can cause both pain and infertility. Currently there is no single and generally accepted classification of endometriosis. Laparoscopy with histological examination is no longer the “gold standard” for diagnosing this disease, which leads to an urgent need to find alternative non–surgical methods. The only presently proven possibility of non–invasive verification of endometriosis is the use of radiation diagnostic methods. TV ultrasound is a first–line imaging modality, but it has limitations in terms of field of view and dependency on the skill and experience of the operator. MRI, used as a method for verifying endometriosis foci, has some limitations in visualizing small endometriotic implants and adhesions, but at the same time, it allows characterizing lesions, studying extraperitoneal localizations and the contents of formations located in the pelvic cavity. Conclusion. The lack of a single generally accepted classification creates difficulties both in the diagnosis of endometriosis and in the selection of the correct treatment for the condition. For the diagnosis of deep endometriotic foci, the specificity and sensitivity are quite high for TV–ultrasound (87–94% and 79–92%), and medium for MRI (77 and 94%), however, for verification of superficial foci, neither MRI nor TV–ultrasound at this moment have superior diagnostic accuracy compared to laparoscopy. Both methods are the most promising, but require improving the quality of diagnostics, which largely depends on the experience of specialists and improving the power of the instruments used. Proper staging of the disease, in turn, will greatly help in choosing the tactics of infertility treatment. Keywords: external genital endometriosis, MRI, ultrasound, "small" forms of endometriosis, non–invasive diagnostics of endometriosis.

Preoperative Ultrasound Scoring of Endometriosis by AAGL 2021 Endometriosis Classification Is Concordant with Laparoscopic Surgical Findings and Distinguishes Early from Advanced Stages

To compare the accuracy of preoperative ultrasound (US) in predicting the laparoscopically defined 2021 American Association of Gynecologic Laparoscopists (AAGL) Endometriosis Staging. Retrospective multicenter study of patients treated at 3 specialized endometriosis centers. Three specialized endometriosis surgical centers in São Paulo (Brazil), Barcelona (Spain), and Avellino (Italy) participated. A total of 878 patients aged 15 to 45 years with no history of pelvic malignancy underwent laparoscopic (LPS) treatment for suspected endometriosis. Retrospective review of preoperative transvaginal and transabdominal US (index test) assessed for endometriosis at all sites used in the 2021 AAGL Endometriosis Classification and classified patients into AAGL-US stages 1 to 4. Results were compared with reference-standard LPS (AAGL-LPS) staging. The AAGL-US and AAGL-LPS stage were concordant in 586 cases (66.7%) (weighted kappa [WK] 0.759; intraclass correlation=0.906), with the highest agreement observed in patients with no endometriosis (n=70, 75.3% concordance), AAGL-LPS stage 1 (104, 50.7%) and stage 4 disease (358, 88.2%). Endometriosis was most accurately diagnosed in the rectum/sigmoid colon (WK 0.862), bladder (WK 0.911), and ovaries (WK 0.835/0.795 for right/left, respectively) and least accurately diagnosed at superficial peritoneal (WK 0.442), tubal (WK 0.391/0.363 for right/left, respectively), and retrocervical/uterosacral ligament (WK 0.656) sites. Sonographic estimation of the 2021 AAGL Endometriosis Staging is greatest in AAGL-LPS stages 1 and 4 and among patients with no endometriosis. US best identifies endometriosis of the ovaries, bladder, and bowel but is more limited for the tubes and superficial peritoneum.

Application of AAGL Endometriosis Classification - An Innovative Tool with Additional Contributions

<h3>Study Objective</h3> To demonstrate application of the innovative newly developed AAGL 2021 endometriosis anatomy-based surgical complexity scoring system and add further contributions. <h3>Design</h3> An overall step-by-step application of the new surgical scoring system developed in 2021 with emphasis on pragmatic utilization of the App through two case reports. <h3>Setting</h3> A university hospital based on Detroit, Michigan; Wayne State University/ Detroit Medical Center <h3>Patients or Participants</h3> A series of two case reports of stage 4 endometriosis based on the Scoring System, including one with endometriosis on the diaphragm. Each patient case demonstrates variety of symptoms and challenges - including pelvic pain and abdominal pain. <h3>Interventions</h3> Application and utilization of the AAGL 2021 Endometriosis Classification. <h3>Measurements and Main Results</h3> Successful identification of intra-operative endometriosis with staging on the AAGL 2021 Endometriosis Classification Scoring System. <h3>Conclusion</h3> Application of AAGL 2021 Endometriosis Classification remains to be very effective in surgical complexity scoring. The classification offers an alternative point system in quantifying endometriotic lesions. This point system allows for a way to numerically scale the disease from a surgical complexity standpoint. Due to its intraoperative utility, the AAGL Endometriosis Classification correlates to pain and avoids limitations that noninvasive imaging may experience and focuses predominantly on pain symptoms. Additional contributions may include addition of extra-pelvic endometriosis, such as the diaphragm. The overall goal is to improve care of endometriosis patients, from addressing chronic pelvic pain, abdominal pain, and fertility complications, with an objective intraoperative staging system.

8627 Evaluating the Feasibility of Assigning 2021 AAGL Endometriosis Classification Scores to Pre-Operative MRI Imaging

<h3>Study Objective</h3> To evaluate the feasibility of applying the AAGL 2021 Endometriosis Classification system to pre-operative MRI findings in order to predict surgical complexity. <h3>Design</h3> A retrospective chart review of patients who had a pelvic MRI performed for the indication of pelvic pain and underwent surgery for presumed endometriosis. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> 190 charts were reviewed of patients referred for an MRI for pelvic pain. Of those patients, 47 had both an MRI and subsequently underwent pelvic surgery. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Of the 190 charts reviewed, 48 patients had both an MRI and underwent pelvic surgery. Using the AAGL Endometriosis Classification system, patients were assigned a score for their MRI and operative findings. When measurements were not specified in the MRI report, they were reviewed on the images or assigned based on terminology of "mild" and "severe." Scores for operative findings were based on explicit use of the scoring system (14.89%) or deduced from the operative and pathology reports. Scores differed significantly for overall AAGL score (t(46) = 3.964, p = 0.00026) with a mean difference between operative and MRI scores of 6.55 (mean operative score of 16.3, SD = 12.54; mean MRI score 9.74, SD = 8.42). Scores differed significantly for stage of endometriosis (t(46) = 4.15, p = 0.0001) with a mean difference between operative and MRI scores of 0.809 (mean operative score of 2.4, SD = 1.48; mean MRI score 1.57, SD = 1.28). <h3>Conclusion</h3> Use of the AAGL Classification system has been implemented to better assess surgical complexity of endometriosis cases. Assigned scores for MRI results, however, differ significantly from operative findings suggesting that there are limitations to the adoptability of this system to imaging findings. Future consistent use of the scoring system in operative reports may improve consistency and more detailed imaging reports may improve accuracy of assigning scores to pre-operative imaging.

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

<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.

8977 The Use and (Potential) Misuse of the AAGL Endometriosis Classification System

<h3>Study Objective</h3> To demonstrate use and (potential) misuse of the AAGL 2021 Endometriosis Classification Scoring System, an anatomy-based surgical complexity scoring system - with the goal of optimizing future endometriosis staging. <h3>Design</h3> A case report applying the new AAGL 2021 Endometriosis Classification and use of the App. <h3>Setting</h3> A university hospital based in Detroit, Michigan; Wayne State University/ Detroit Medical Center. <h3>Patients or Participants</h3> A case report of a Stage 2 Endometriosis based on the Scoring System with a patient presenting for infertility. <h3>Interventions</h3> Application and utilization of the AAGL 2021 Endometriosis Classification for a Stage 2 Endometriosis Classification. <h3>Measurements and Main Results</h3> Scoring system demonstrated feasibility, applied utility to the correlation that was discussed regarding the Scoring System, but also limitations and potential misuses of the scoring system. <h3>Conclusion</h3> The AAGL Endometriosis Scoring System is a feasible intraoperative scoring system correlated with pain. It is critical to be cognizant of staging parameters while scoring the endometriotic lesions and remaining consistent.