S. Reid

Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements : A consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real‐time dynamic transvaginal ultrasound technique: the sliding sign

To evaluate preoperative real‐time dynamic transvaginal sonography (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis.

Office gel sonovaginography for the prediction of posterior deep infiltrating endometriosis: a multicenter prospective observational study

To use office gel sonovaginography (SVG) to predict posterior deep infiltrating endometriosis (DIE) in women undergoing laparoscopy.

Sonovaginography: redefining the concept of a “normal pelvis” on transvaginal ultrasound pre‐laparoscopic intervention for suspected endometriosis

Office sonovaginography (SVG) challenges the concept of the “normal” pelvic ultrasound in women with chronic pelvic pain and suspected endometriosis. When positive for posterior compartment deep infiltrating endometriosis, with or without Pouch of Douglas obliteration, office SVG allows for triaging of women to the appropriately trained advanced laparoscopic gynaecological and colorectal surgical team. We advocate that all women with suspected endometriosis undergo office SVG prior to laparoscopy to ensure an accurate pre‐operative mapping of endometriosis disease location and extension.

Performance of ultrasound-based endometriosis staging system (UBESS) for predicting level of complexity of laparoscopic surgery for endometriosis

To develop and assess the performance of a preoperative ultrasound‐based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis.

Systematic Evaluation of Women With Suspected Endometriosis Using a 5-Domain Sonographically Based Approach

In recent years, knowledge has evolved regarding the role of transvaginal sonography in the assessment of the pouch of Douglas status and the preoperative prediction of extraovarian endometriosis in specific locations. Despite these advances in transvaginal sonography, the challenge of developing a comprehensive, cost‐effective, and reproducible preoperative classification system for endometriosis remains. Critical to this classification system should be a sonographically based evaluation protocol that is systematic, evidence based, and reproducible with clearly defined end points. To date, no structured evaluation protocol exists for the assessment of the pelvis in women with suspected endometriosis. In this article, we propose a domain‐based evaluation protocol for the assessment of women with suspected endometriosis using transvaginal sonography.

The ‘sliding sign’ in conjunction with sonovaginography: is this the optimal approach for the diagnosis of Pouch of Douglas obliteration and posterior compartment deep infiltrating endometriosis?

Introduction: Endometriosis is a chronic peritoneal disease that may progress as a deep infiltrating lesion involving the posterior compartment of the pelvis. Efforts to improve pre‐operative knowledge of the location and extent of these lesions have resulted in the development of Transvaginal ultrasound (TVS) as the first‐line imaging modality for extra‐ovarian endometriosis. However, various techniques of TVS have been described in the literature for this purpose.

Transvaginal sonographic sliding sign: accurate prediction of pouch of Douglas obliteration.

Several studies have evaluated the accuracy of transvaginal ultrasound (TVS) in the prediction of deep infiltrating endometriosis (DIE)1–6; however, few studies have reported on the ability of TVS to predict pouch of Douglas (POD) obliteration. POD obliteration is diagnosed when the peritoneum of the POD is no longer visible during surgery, and it occurs as a result of adhesion formation between the posterior aspect of the uterus/cervix and surrounding structures such as the anterior rectum, rectosigmoid bowel, rectovaginal septum, vagina or uterosacral ligaments. The primary causes of POD obliteration include pelvic inflammatory disease and DIE. POD obliteration may also occur as a result of extensive superficial endometriosis infiltrating the peritoneum of the POD and adjacent structures. The surgical finding of POD obliteration is known to be associated significantly with symptoms such as dyspareunia and rectal bleeding7,8. The ability to diagnose POD obliteration at initial pelvic ultrasound examination not only may be helpful in explaining the possible cause of pelvic pain symptoms, but also may shed light on the potential severity of underlying endometriotic disease. When POD obliteration is encountered at laparoscopy, advanced laparoscopic skills are required to separate the adhesions in the POD and excise any associated posteriorcompartment DIE lesions. The risk of bowel endometriosis and the need for bowel surgery is known to be up to three times higher in women with suspected endometriosis if the POD is obliterated at laparoscopy7,9. Given the increased complexity of the surgery and prolonged operating times associated with POD obliteration, it is very useful for the laparoscopic surgeon to know the status of the POD preoperatively. Inability to predict POD obliteration with posterior compartment DIE on preoperative TVS has two important implications. One is the potential for incomplete surgical cytoreduction of posterior compartment endometriotic disease when a general gynecological surgeon without the necessary operative skills is unexpectedly confronted with POD obliteration intraoperatively. Affected women then have to be referred to a tertiary laparoscopic unit for a second laparoscopic procedure. The second is the need for unplanned intraoperative consultation and surgical input by a colorectal surgeon, when an advanced laparoscopic surgeon is confronted with POD obliteration and bowel disease during the surgery. Knowing whether or not the POD is obliterated ensures that the woman is referred to the most appropriately skilled laparoscopic surgeon from the outset and streamlines patient counseling and consent preoperatively, in terms of expectations for surgery and the possible need for bowel intervention with its associated morbidities. Both TVS and magnetic resonance imaging (MRI) have been used to predict DIE involving the posterior compartment. In a recent study by Savelli et al.10, 69 women were evaluated with TVS and with double-contrast barium enema (DCBE) to predict posterior compartment DIE preoperatively. With regard to the prediction of bowel DIE, TVS vs DCBE gave accuracy of 91% vs 45%, sensitivity of 91% vs 43%, specificity of 100% vs 100%, positive predictive value (PPV) of 100% vs 100% and negative predictive value (NPV) of 29% vs 6%. The TVS assessment for bowel endometriosis included placing gentle pressure with the transvaginal probe in the area of interest, to determine the fixation of the endometriotic nodule to adjacent structures. Another recent study by Vimercati et al.11 examined 90 women with suspected DIE using preoperatively both contrast-enhanced magnetic resonancecolonography (CE-MR-C) and TVS to predict DIE. In the diagnosis of adhesions of the rectosigmoid colon, TVS and MRI had an accuracy of 82% and 98%, sensitivity of 68% and 100%, specificity of 96% and 96%, PPV of 94% and 96%, NPV of 76% and 100%, positive likelihood ratio of 16 and 23 and negative likelihood ratio of 0.3 and 0. The conclusion from these two studies was that TVS is an accurate and cost-effective imaging method in the prediction of DIE involving the posterior compartment. However, neither of these studies reported on the ability of TVS to predict specifically POD obliteration. The few ultrasound studies that have used TVS to predict POD obliteration preoperatively have shown promising results, with sensitivities and specificities ranging from 72–83% and 97–100%, respectively1,7,12. In a study published in this issue of the Journal, we report on the use of the TVS ‘sliding sign’ technique in the preoperative prediction of POD obliteration7. The sliding sign uses gentle pressure by the TVS probe to assess whether the anterior rectum glides freely across the posterior aspect of the cervix and posterior vaginal wall and whether the rectosigmoid glides freely over the posterior aspect of the posterior upper uterus. When sliding occurs (i.e. the sliding sign is positive) in both of these anatomical regions the POD is considered to be unobliterated. When sliding does not occur in either anatomical region the sliding sign is considered negative and the POD is considered obliterated. In women with suspected endometriosis undergoing laparoscopy we found that the sliding sign had an accuracy of 93% in the preoperative prediction of POD obliteration. While this sign appears to be a simple

Can we improve the prediction of pouch of Douglas obliteration in women with suspected endometriosis using ultrasound-based models? A multicenter prospective observational study

A negative “sliding sign” during transvaginal sonography (TVS) is associated with pouch of Douglas (POD) obliteration at laparoscopy in women with suspected endometriosis. The aim of the current study was to develop and validate mathematical ultrasound models to determine whether a combination of TVS markers could improve the prediction of POD obliteration as compared with the TVS “sliding sign” alone.

A prediction model for viability at the end of the first trimester after a single early pregnancy evaluation

The aim was to develop a new model to predict the outcome at the end of the 1st trimester after a single visit to the early pregnancy unit (EPU).