Ultrasound as a noninvasive diagnostic tool to detect deep endometriosis using the International Deep Endometriosis
Celine Bafort1, George Condous2, Dominique Van Schoubroeck3
1Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
Objective:
To evaluate the performance of transvaginal ultrasound (TVS) using the International Deep Endometriosis Analysis (IDEA) terminology in the detection of deep endometriosis (DE).
Design:
International multicenter prospective diagnostic accuracy study involving eight academic centers in eight countries (September 2019 - November 2023). The index test was TVS performed in accordance with the IDEA consensus statement. Reference standard was the direct visualization of endometriosis at laparoscopy.
Subjects:
Patients with suspicion of DE were included.
Exposure:
A total of 1,796 consecutive patients underwent TVS performed according to the IDEA terminology (index test) of which 1,182 subsequently underwent laparoscopic surgery (reference test). On the basis of direct surgical visualization 1,140/1,182 (96.4%) had endometriosis, of whom 923/1,182 (78.1%) presented with DE.
Main Outcome Measures:
Area under the curve (AUC), sensitivity, specificity, positive and negative predictive value (PPV and NPV) were calculated to assess the performance of TVS to detect DE.
Results:
Median age was 32 years. 76% were nulliparous, 41% used hormonal therapy at baseline, and 30% had undergone previous endometriosis surgery. The vast majority (92%) experienced dysmenorrhea and 32% presented with infertility. 34% had sonographic signs of adenomyosis. For DE overall, the diagnostic performance of TVS was as follows: AUC 0.88 (95% confidence interval [CI] 0.85-0.90), sensitivity 95% (95% CI 94%-97%), specificity 80% (95% CI 75%-85%), PPV 95% (95% CI 93%-96%), NPV 82% (95% CI 77%-87%). Sensitivity was highest for bowel DE (87%, 95% CI 83%-90%) followed by left uterosacral ligament (USL) (78%, 95% CI 74%-82%). The sensitivity was lowest for the rectovaginal septum (51%, 95% CI 44%-58%). Specificity was highest for bladder DE (99%, 95% CI 99%-100%) and lowest for the left USL (87%, 95% CI 84%-89%).
Conclusion:
Noninvasive diagnosis of DE with TVS performed in accordance with the IDEA consensus statement has a high diagnostic accuracy. Implementation of the IDEA methodology in daily gynecological practice has the potential to shorten the diagnostic delay and expedite treatment strategies. Accurate DE mapping may improve triaging referral of patients, trigger a multidisciplinary team, and potentially mitigate operative risks, resulting in a reduced financial burden.
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