Uche Menakaya

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

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.

Interpreting the real-time dynamic 'sliding sign' and predicting pouch of Douglas obliteration: an interobserver, intraobserver, diagnostic-accuracy and learning-curve study.

To determine inter‐ and intraobserver agreement, diagnostic accuracy and the learning curve required for interpreting the ‘sliding sign’ and predicting pouch of Douglas (POD) obliteration.

Integrating the concept of advanced gynaecological imaging for endometriosis

It is now more than four decades since sonography was first used to evaluate the obstetric patient. At its beginning, the questions asked were basic. For example, is there a live pregnancy? Is there a singleton or a twin gestation? Where is the placenta located? At the time, it was not immediately envisioned that sonography would be a very useful diagnostic modality that could answer questions related to the presence of subtle anatomical defects such as cleft lip and palate, suggest the presence of chromosomal abnormalities or contribute to the clinical management of the growth-restricted fetus. Now days it is not unusual for women to have one or even several ultrasound examinations during a pregnancy. Clear pathways for escalating the management of fetal anomalies identified at community-based imaging centres have become embedded in quality assurance programs. Maternal-fetal medicine centres of excellence for advanced obstetric imaging as well as surgical and medical management of amenable fetal anomalies have become established. Indeed, the recent technological advances in ultrasound imaging, the use of high-frequency ultrasound probes with 3D capabilities and its utilisation for chromosomal and growth restriction screening in early pregnancy continue to magnify our interest in the use of sonographic imaging for the obstetric patient. For the gynaecological patient, the evolution of gynaecological imaging is demonstrating a similar trajectory. In the last two decades, gynaecological imaging has moved beyond routine measurements of the uterus and adnexae and the description of adnexal masses as simple or complex. It now has a role in the triage of adnexal lesions, the quantification of female pelvic organ prolapse, the preoperative assessment of the pelvis in women planning surgery for endometriosis and procedural gynaecological imaging such as saline/contrast sonohysterosalpingogram. This evolution of gynaecological imaging is not only a consequence of the technological advances in ultrasound imaging but also related to the emergence of women’s health specialists with special interest and training in gynaecological imaging. With the evolution of gynaecological imaging and the emergence of specialists with experience and training in this speciality, it is now imperative to establish and integrate clear referral pathways for escalating sonographic anomalies identified in a gynaecological patient similar to that currently in place for the obstetric patient. Such a hierarchical approach to evaluating gynaecological anomalies was demonstrated by the International Ovarian Tumor Analysis (IOTA) group when they externally validated a two-step strategy for assessing adnexal lesions where the simple rules for characterising adnexal masses yielded an inconclusive result with less experienced operators. This two-step strategy reached a sensitivity of 90% and a specificity of 93% for detecting ovarian malignancy and is now included in the RCOG guidelines for evaluating ovarian pathology in premenopausal women. The principles underpinning this two-step approach described by the IOTA group is also feasible for the sonographic assessment of the pelvis in women with suspected endometriosis. For example, an endometrioma is a common phenotype of endometriosis. Characteristically, endometriomas appear as unilocular or multilocular (up to 4 locules) adnexal cysts with ground glass echogenicity of the cyst fluid and no solid papillations They are easily classifiable using pattern recognition and/or the simple rules approach. They are also soft markers for higher stage endometriosis and often occur in association with other phenotypes of endometriosis. Indeed, evidence demonstrates that more than 50% of endometriomas are associated with other phenotypes of endometriosis. The presence of endometriomas in women presenting with pelvic pain therefore could only be a ‘tip of the ice berg’ in the disease spectrum of endometriosis and should mandate a careful search for other phenotypes of endometriosis (bowel and uterosacral deep endometriosis) and their markers of local invasiveness (ovarian adhesions and POD obliteration) using transvaginal ultrasound (TVS) This is important because for symptomatic women with endometriomas, preoperative characterisation of disease severity is critical to appropriate surgical management especially as maximal cytoreduction at the first surgical intervention delivers the greatest benefit. With the evolution of transvaginal sonography as the first-line imaging modality for evaluating the pelvis in women with suspected endometriosis, its utilisation must employ systematic, objective and reproducible TVS techniques that will facilitate comparisons between and within units involved with endometriosis ultrasound. However, proficiencies in these new TVS techniques for evaluating the pelvis in women with suspected endometriosis require additional training and expertise beyond that available for performing routine gynaecological imaging. This is especially important as emerging evidence now demonstrates different learning curve parameters for these various phenotypes of endometriosis. More recently, Menakaya et al. described a five-domain TVS-based approach to the evaluation of the pelvis in

The retroverted uterus: refining the description of the real time dynamic ‘sliding sign’

Ultrasound techniques currently employed in the definition of posterior compartment deep infiltrating endometriosis (DIE) are now well described. These include the sonovaginography, first described by Dessole in 2003, for mapping the location and extent of posterior compartment DIE and more recently the real time dynamic ‘sliding sign’ for the assessment of the status of the Pouch of Douglas (POD). The real time dynamic ultrasound-based ‘sliding sign’ deserves special mention. There is now evidence demonstrating high accuracy for prediction of POD obliteration using the ‘sliding sign’ technique. As a tool for assessing the status of the POD, its value in the pre-operative work up of women with potential posterior compartment DIE cannot be overemphasised. More than 60% of women with an obliterated POD have evidence of bowel endometriosis and therefore laparoscopic surgery is more difficult and longer duration. Therefore pre-operative knowledge of the status of the POD can be extremely helpful in streamlining surgical planning and allocation of appropriate laparoscopic skill mix. As a test, the ‘sliding sign’ has also demonstrated high reproducibility and accuracy among different operators. Furthermore it is an easy technique to demonstrate, however the descriptions to date have not taken into account the position of the uterus, i.e. whether the uterus is anteverted or retroverted. In fact the technique described in the literature presumes the uterus is anteverted. In order to assess the real-time ultrasoundbased ‘sliding sign’ in an anteverted uterus, gentle pressure is placed against the cervix with the transvaginal probe to establish whether the anterior rectum glides freely across the posterior aspect of the cervix (retro-cervical region) and the posterior vaginal wall. If the anterior rectal wall does glide smoothly over the posterior cervix and posterior vaginal wall then the ‘sliding sign’ is considered to be positive for this location. The examiner then places the left hand over the woman’s lower anterior abdominal wall in order to ballot the uterus between the palpating hand and transvaginal probe (being held in the right hand) to determine whether the anterior recto-sigmoid glides freely over the posterior aspect of the upper uterine fundus. If the anterior recto-sigmoid wall does glide smoothly over the posterior upper uterine fundus during the transvaginal scan The retroverted uterus: refining the description of the real time dynamic ‘sliding sign’

Diagnostic laparoscopy in pre‐surgical planning for higher stage endometriosis: Is it still relevant?

It has become necessary to re ‐ examine the relevance of diagnostic laparoscopy in the two‐stage approach to surgical management of symptomatic women with higher stage endometriosis following emerging evidence demonstrating acceptable diagnostic performance of alternative less invasive and less expensive imaging modalities. We highlight the relative merits of these presurgical diagnostic imaging modalities and propose strategies that address the challenge of transitioning to a new diagnostic paradigm in the management of symptomatic women with higher stage endometriosis.

Interpreting the real‐time dynamic ‘sliding sign’ and predicting POD obliteration: an inter‐, intra‐observer, diagnostic accuracy and learning curve study

To determine inter‐ and intraobserver agreement, diagnostic accuracy and the learning curve required for interpreting the ‘sliding sign’ and predicting pouch of Douglas (POD) obliteration.

Relating historical variables at first presentation with operative findings at laparoscopy for endometriosis

To determine the correlation between historical variables at presentation with the phenotype and location of biopsy proven endometriosis at laparoscopy.