Proposed new MRI scoring system of rectosigmoid endometriosis to guide operative planning

Rectosigmoid endometriosis (RSE) presents with a diverse array of MRI findings that impact surgical planning. No standardized reporting and data system has been established for RSE.

We propose a novel MRI scoring system designed to predict the likelihood of muscularis propria (MP) involvement in RSE, which would, in turn, influence surgical planning.

The records of patients with bowel endometriosis treated surgically from May 2018 to June 2022 were retrieved. Surgery was classified as partial thickness discoid, full thickness discoid, or segmental resection. Each pre-treatment MRI was scored based on the mutual agreement of two abdominal radiologists (reference score). The MRI score was defined as (1) score 0: no evidence of RSE, (2) score 1: minimal tethering involving the serosal surface without MP involvement, (3) score 2: intermediate soft tissue thickening involving the rectosigmoid colon with indeterminate MP involvement, or (4) score 3: definite mushroom cap sign or definite MP involvement. In the reader study, two radiologists independently scored each exam. The area under the curve (AUC) was evaluated for predicting the need for segmental or full thickness discoid resection.

The cohort consisted of 95 patients (median age: 36 years); 16, 14, 30, and 35 patients had MRI score 0, 1, 2, and 3, respectively. Patients with MRI scores 3 and 2 underwent partial thickness discoid (6% vs. 50%), full thickness discoid (6% vs. 17%), and segmental resection (89% vs. 33%), respectively. All patients with MRI scores 1 or 0 either underwent partial thickness discoid resection or did not undergo rectosigmoid surgery. The AUCs were 92.2%, 84.5% and 93.9% for MRI scores of the reference, reader 1, and 2, respectively.

Our MRI scoring system based on suspected depth of bowel invasion showed good diagnostic performance to predict the type of surgical intervention needed.