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Saeed Alborzi , M.D . Professor of Obstetrics & Gynecology

A comparison of pelvic magnetic resonance imaging, trans-vaginal and trans-rectal sonography with laparoscopic findings in diagnosis of deep infiltrating endometriosis. Saeed Alborzi , M.D . Professor of Obstetrics & Gynecology Specialist in Infertility & Gynecologic Endoscopy

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Saeed Alborzi , M.D . Professor of Obstetrics & Gynecology

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  1. A comparison of pelvic magnetic resonance imaging, trans-vaginal and trans-rectal sonography with laparoscopic findings in diagnosis of deep infiltrating endometriosis Saeed Alborzi, M.D. Professor of Obstetrics & Gynecology Specialist in Infertility & Gynecologic Endoscopy Shiraz University of Medical Sciences, Shiraz, Iran

  2. Introduction • Endometriosis is defined as an ectopic presence of endometrial tissue outside the uterus. • Affects 5-10% of women of reproductive age • Superficial endometriotic implants are mostly silent and asymptomatic • lesions lying deeper than 5mm within the peritoneum (DIE) are associated with more severe symptoms. • Common locations for DIE are uterosacral ligaments, posterior vaginal wall and anterior rectal wall • 15-30%of patients with endometriosis suffer from DIE

  3. Diagnosis of DIE is an uphill challenge for gynecologists. • Direct visualization and biopsy of lesions through laparoscopy or laparotomy remains the gold standard method for definitive diagnosis. • Various imaging modalities such as MRI, TVS, TRSas well as 3D ultrasound are currently available for the diagnosis of DIE. • Considering the cost-effectiveness and accessibility issue, TVS is usually the first diagnostic imaging modality in females with symptoms of DIE. When performed by an expert radiologist, TVS is reported to have a sensitivity of 98.1% and 95.1% for diagnosis of rectal and retrocervical DIE, respectively. • MRI is a more expensive and meanwhile non-invasive modality for pre-operative assessment of DIE which provides more accurate data about the extension, localization and penetration of the lesions. The sensitivity of MRI for diagnosis of rectal and retrocervical DIE has been reported 83.3% and 76%, respectively.

  4. choosing the best imaging modality for diagnosis and pre- operative assessment is still a challenging issue. The aim of this study was to compare the accuracy and define sensitivity and specificity of three different imaging modalities (TVS, MRIand TRS) in a large population of DIE patients referred to a tertiary gynecological surgery centers As far as we reviewed the literature, this study included one of the largest population of patients with endometriosis for whom three different imaging techniques were used to assess preoperative diagnosis of DIE.

  5. Materials and methods • From March 2010 to December 2014 • in a prospective manner • Patients referred to private clinics and hospitals affiliated to Shiraz University of medical sciences • With symptoms of chronic pelvic pain, dyspareunia and dysmenorrhea, who were candidate for operative laparoscopy with suspicion to DIE were enrolled in this study • Over 500 patients underwent laparoscopic surgery ,317 cases (only non-virgins) were enrolled in our study (due to lack of possibility of TVS evaluation in virgin subjects) • All patients were asked to sign the informed consent • Patients were included from all age groups

  6. Exclusion criteria 1-Claustrophobia from MRI tunnel 2-Renal failure or any other contraindication for gadolinium contrast medium injection 3- History of having metallic implants or prosthetics in the body which prohibits the use of MRI 4-Structural anomalies of the reproductive system 5-Patients’ refusal or incompliance with TVS or TRS

  7. Trans-vaginal sonography • Using 7.5 MHz probe in non-menstrual days of the cycle for non-virgin pts. • Patients were asked to have empty bladder and simple bowel prep for better visualization of pelvic organs. • Examination protocol included visualization of peritoneum and structures in anterior and posterior compartments, as well as uterus and ovaries. • Nodular, hypoechoic solid lesions with and without cystic components, in different structures of pelvic cavity were considered to be highly suggestive for DIE. • Also hyper-echogenic abnormal thickening of the peritoneum over structures in pelvic cavity was considered as a sign of DIE.

  8. Transrectalsonography • TRS was performed on the same day that TVS was done, by the same attending gynecologist using 7.5 MHz probe after bowel preparation • Bowel prep is achieved by asking the individuals to have a soft diet in the day before sonography, having 2 spoonfuls of MOM orally after lunch and by rectal administration of bisacodyl(2 suppositories TID on the day before the procedure). They were asked not to have breakfast and also take 2 bisacodyl suppositories at 6 am in the next morning • The procedure was performed with empty bladder and by using lubricant gel without administration of sedatives • Examination protocol included the same structures which were examined in TVS and the same diagnostic criteria were used

  9. Magnetic resonance imaging • MRI was performed for all patients after 4-hour fasting with semi-filled bladder, before and after injection of gadolinium contrast medium, with dosage of 0.01mmol/kg, using 1.5 Tesla using body pelvic coil without endovaginalcoil • 60cc lubricant gel was inserted into the vaginal cuff for better delineation of rectal and vaginal walls, and hyoscine 1 Amp IM injected • Protocols include Axial, Coronal and Sagittal T1-and T2-weighted images to delaminate the anatomy and pathology • T1 Axial and Sagittal fat saturation technique with and without contrast is also performed • The bladder wall and rectovaginal septum are evaluated in T2 Sagittal and Axial image • Uterosacralligaments and rectal wall mostly in coronal and Axial T2 weighted image • Endometriomaswere high signal in T1 and low signal in T2 weighted images • DIE were low signal or signal void in T2 weighted images • Thickening of the walls were in favor of involvements

  10. Laparoscopy • Operative laparoscopy was performed by the same gynecologist in all patients after whole bowel prep under general anesthesia. • Two 10 mm and two 5mm ports were used. • The pelvic cavity was explored and endometriosis was classified according to the revised American Society for Reproductive Medicine (rASRM) classification (1985) • According to different locations, pararectal and paravesical and rectovaginal spaces were dissected when necessary • All adhesions were released with sharp dissection and all lesions suspicious to DIE were resected to the extent to restore normal anatomic relations and sent for pathologic investigation

  11. For rectal lesions, pararectal and rectovaginal spaces were dissected and inspected for suspicious areas, and the suspicious lesions were excised, disk resection or segmental resection and reanastomosis of bowel was performed as necessary. • For those patients with extrinsic ureteral lesions, ureterolysis, and for those with intrinsic ureteral lesions, excision and reanastomosis were performed. • In patients who presented with bladder lesions, either shaving or partial cystectomy was done according to the depth of lesions.

  12. Results • Our study population comprised 317 women with signs and symptoms of endometriosis in the age range of 15 to 50 yrswith a mean age of 31 ± 5.4 ys. • All patients who enrolled in this study underwent laparoscopy and 350 DIE lesions were detected. • In 65 out of 317 patients (20 %), laparoscopy yielded negative results for DIE through the patients might have had endometrioma or superficial endometriosis. • Among 350 DIE lesions, 151 were located within the uterosacral ligaments (43%) as the most frequent site of involvement followed by ovarian fossa (n=59, 16.9%), rectal wall (n=52, 14.9%) and rectovaginal septum (n=44, 12.6%), respectively.

  13. With regard to TVS, 310 lesions were visualized of which 254 were approved by laparoscopy. • The comparison between TVS and laparoscopic findings for DIE lesions are presented in next table .

  14. For TRS, out of 339 diagnosed DIE lesions, 270 were confirmed by laparascopy. • The achieved results are outlined in next table.

  15. With respect to pelvic MRI, 286 lesions were detected out of which 238 lesions were confirmed by laparascopy. • Detailed comparison is provided in next table .

  16. Comparison of TVS, TRS and MRI for specific locations of involvement with DIE • For the lesions within uterosacral ligaments as the most prevalent site of DIE involvement, TRS was shown to have a better sensitivity than TVS and MRI (82.8% vs. 70.9% and 63.6%, respectively) and a lower miss rates (0.17 vs. 0.29 and 0.36, respectively). Nevertheless, specificity had a reverse trend and was better for MRI (93.9% vs. 92.8% and 89.8% for TVS and TRS, respectively). • For the lesions located in the rectovaginal septum, the sensitivity and accuracy were more favorable in TVS rather than TRS and MRI (86.4%, 93.7% vs. 84%, 92.4% and 72.7%, 92.1%, respectively). Meanwhile, the specificity was higher in MRI as compared to TVS and TRS (95.2% vs. 94.9% and 93.8%, respectively).

  17. For the ovarian fossa DIE lesions, MRI was more sensitive than TRS and TVS (66.1% vs. 64.4% and 62.7%, respectively). Furthermore, specificity and accuracy were better with MRI and TVS as compared to TRS (98.1%, 92.1% vs. 95.7%, 89.6% and 93.4%, 88%, respectively). • Concerning the lesions within the rectal walls, TVS was superior to TRS and MRI in its sensitivity and specificity (88.5%, 98.9% vs. 86.5%, 97.7% and 76.9%, 96.6%, respectively). • MRI was found to be superior to TRS and TVS in terms of sensitivity, specificity and accuracy for retrocervical DIE lesions

  18. For bladder and uretralDIEs however, the three modalities were observed to have the same results for the diagnosis of DIE. The sensitivity, specificity and accuracy for the three tests were 100%, 99.68%, and 99.68%, respectively

  19. Comparison of TVS, TRS and MRI regarding total lesions • Regardless of anatomical location, TRS possessed marginally higher sensitivity for the diagnosis of DIE lesions than TVS and MRI (81.1% vs. 80.1% and 77.9%, respectively). • Meanwhile, the specificity was slightly higher for MRI as compared to TVS and TRS (97.1% vs. 96.6% and 95.8%, respectively). • TRS held a similar accuracy compared to TVS and MRI (93.3% vs. 93.1% and 92.8%, respectively).

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