Preoperative Sonographic Evaluation of Deep Infiltrating Endometriosis

Study Objective

To demonstrate the utility of preoperative sonographic evaluation for deep infiltrating endometriosis (DIE) and correlate ultrasound and intraoperative findings through a clinical scenario.

Design

A stepwise demonstration and comparison of ultrasound and intraoperative evaluation of DIE with narrated video footage.

Setting

A tertiary, academic hospital with an experienced endometriosis sonographer and high-volume MIGS specialist.

Patients or Participants

A 25-year-old presented with chronic pelvic pain and history of endometriosis after failing multiple medical therapies.

Interventions

DIE occurs in 4-37% of patients with endometriosis. Ultrasound is recommended as a first-line imaging for evaluation and has high sensitivity and specificity for DIE. At our institution, same day preoperative ultrasound is performed for patients based on the IDEA group consensus on the systematic approach to sonographic evaluation of endometriosis. This evaluation includes a basic assessment of the uterus and adnexa, soft markers such as sliding sign, and the anterior and posterior compartments of the pelvis.

Measurements and Main Results

In this patient, ultrasound illustrated an immobile uterus with a 3 cm right ovarian endometrioma and two hypoechoic lesions in the posterior cul-du-sac, indicating adhesive disease and advanced-stage endometriosis. The patient had a laparoscopic resection of endometriosis, right ovarian cystectomy, bilateral ureterolysis, adhesiolysis and enterolysis, rectal shaving, and an appendectomy. Sonographic results correlated accurately with intraoperative findings, and the pathology was consistent with endometriosis.

Conclusion

Ultrasound is imperative for assessing patients with suspected or confirmed advanced-stage endometriosis. A structured pelvic ultrasound should be completed in a manner that assesses for uterine and adnexal mobility and endometriosis lesions or nodules in the anterior and/or posterior compartments of the pelvis. This type of evaluation allows for appropriate surgical planning and counseling, especially for advanced laparoscopic procedures. However, there needs to be more specialized sonographic training to improve the accuracy of preoperative sonographic evaluation of endometriosis.