International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Good Sonogram is Best for Guidance for Successful Endometriosis Surgery - Alessandra Di Giovanni, MD
Hi everyone and thanks Kay for the opportunity to participate in this amazing event even from remote. Let's see together why I do prefer ultrasound for endo diagnostic. We have several reasons to need accurate imaging for s of endometriosis. First of all, laparoscopy cannot be considered diagnostic tool. Since it's expensive, it implies some surgical risk and most of all, it may fail to recognize some specific lesions such as the completely retro peroneal ones. So reliable imaging can contribute to an accurate assessment not only in terms of presence or absence of the disease, but it allow us to evaluate the disease extent and thus reduction the number of surgical procedure limiting them to that patients who effectively need surgery. The precise assessment of the disease severity can also aid to plan better our surgical strategy and to put together a multidisciplinary team when needed. Accurate. Preparative imaging can help us to decrease the number of useful surgeries or death surgeries that are incomplete due to lacking knowledge about the true extent of the disease and its complexity, and to refer patients to X per center.
So when diagnosis is deep infiltrating endometriosis examiner experience is the most crucial factor to be considered. So if I have to answer to the question why I do prefer ultrasound for endo diagnostic, the first answer is that I am and a gynecologist who has deep knowledge of the disease and high expertise in ultrasonography can better identify in the method lesion when compared to general gynecologist who has less experience in the field. The same happens for MRI when radiologists who are experts in female pelvic imaging are compared to general radiologists with less experience and less knowledge of the disease, the diagnostic accuracy is far different. And so that gynecologic surgeon when refer patients for imaging dialysis should recommend them and refer them to facilities with adequate. We did advancing tech. We came to the point that both ultrasonography and MRI are nowadays considered the gold standard for the axis of endometriosis with similar diagnostic accuracy when performed by at a glance, we can see that transferred vaginal scan and MRI show almost the same sensitivity and specificity when compared about the different location of deep infiltrating endometriosis.
Recently this international consensus statement was published. It was a N Society consensus with experts from all over the world, surgeons, radiologists, sonographer, reproductive men's in specialists, all agreeing about the prominent role of both ultrasonography and MRI as noninvasive imaging technique for accurate XI of the pelvic endometriosis. Given to our capability to identify norotic lesion in all pelvic and abdominal compartments, we came to the point to provide both with ultrasonography and MRIA real mapping of the disease with the opportunity to perform a presurgical evaluation, classification and staging of the disease. Current guidelines emphasize the role of imaging in the axis. Endometriosis clinical examinations is of course crucial, but it's not enough in order to provide information about the extent of the disease and use of imaging is encouraged in that symptomatic woman in which clinical examination is a negative. Current recommendation suggests transvaginal scan as the first line imaging approach for patients with suspicion or dxi endometriosis and transabdominal ultrasound as an alternative when transvaginal root is not appropriate or not feasible.
However, transabdominal evaluation should be always performed in order to observe the upper abdominal quadrant and to make a proper evaluation of the disease extent. MRI is suggested as a second line imaging, but when we perform MRI, we should be absolutely sure it's performed by expert operator and there is still some space for diagnostic laparoscopy, but just in that cases of patients with high clinical suspicion in which imaging performed by experts, so both ultrasonography and MRI are negative. And also in that case in which we ask for diagnostic laparoscopy, we should be sure about the fact that it's performed by surgeon that are experts in the field. So by of transvaginal and transabdominal ultrasonography or transrectal where needed, we can provide information that can be relevant for clinical and surgical management of the patient. Of course, we can also perform intraoperative imaging if needed, but we are absolutely convinced about the fact that all the information that we collect are best to know before in order to set a proper surgical strategy. And most of all to counsel patients about the type of surgical procedure they are going to undergo risk benefits and expectation about the proposal. So let's see together how we can make a proper of deep infiltrating endometriosis bosa. The idea consensus published in 2016 provided us terms and definition in order to identify and classify deep infiltrating anato lesion in different pelvic compartments. The typical deep infiltrating nodule that can be visualized. Bio ultrasound is a solid hyper co lesion with I regular margins and poor vascularity.
We should look for this kind of lesion in all that pelvic and abdominal compartment in order to achieve a complete evaluation of the disease. Of course by ultrasonography, we can also identify lesion at a typical sites. For example, at the level of the wound at abdominal wall, at the level of the groin, the novel and also very, very thin lesion at the and superficial lesion at the level concerning a bladder nole. We have high specificity. Sensitivity in some study is low probably because when the bladder is observed completely empty, the risk is to Ms. Small nole with the morphology plaque that don't protrude into the lumen. So the advice is to observe always the bladder not completely empty with a small amount of urine that can help us to underline the wall and to detect and identify deep infiltrating lesion. Once identified the lesion beyond the evaluation of the diameters, we should assess the location at the level of the bladder and the majority of cases we have a nodule of the base of the bladder or the level of the treatment, more rare at the level of the dome.
And we should assess the distance from ureter Miata and ureter inal segment in order to provide surgeon information about the surgical complexity concerning phonics and retro vaginal septum. That lesion are for sure the most easily to be identified by pelvic bimanual examination, but once again, imaging can provide us more and more information about the extent of the disease. Concerning bowel nodules, we can cover by ultrasound area in which the majority of deep infiltrating nodules lie more than 90%. And this is also the reason why we usually don't task for MRI in case of a deep infiltrating lesion of the bowel. This is the typical appearance of a deep infiltrating nodule of the bowel wall with infiltration of mainly of the muscularis. It's really rare the infiltration of inner layer of the bowel wall. And this is also the reason why colonoscopy is usually not required to achieve a correct dialysis because infiltration of the mucosa is very rare and when it happens, you are just looking at the tip of the iceberg. So ultra sonography and of course MRI are very accurate in identify lesion and measure the diameters that are crucial for surgical planning.
Here we can see how to properly identify and measure the deep infiltrating nodule of the bowel, giving information about the depth of infiltration, the length of the bowel. I have to underline that it's our habit to follow the axis of the bowel wall in order to avoid another estimation of the lesion. Then of course we can provide information about the transversal extension of the lesion and the percentage of the circumference cell involvement. And we can also as well distinguish the component of the bowel that is the true infiltration at the level of the muscularis when compared with superficial disease at the level of the SHOs that shows at different echogenicity. Of course, we can complete our valuation of the bowel also by giving information about the distance from the lower margins of the nole to the annal ver that can predict surgical complexity and risk of complication.
We can also cover by ultrasound with a combination of transvaal transabdominal approach the right iliac fossa by identifying nole at the level of small bowel cecum and appendix. In that case, it's also the three evaluation can be of some help to better understand the morphology of the nodule when multiple segments are involved with. By following these rules, we can achieve a very high diagnostic accuracy, almost 100% on rectal smide junction and sigmoid with a slow decrease in sensitivity concerning ilum seum, especially that small nodule at the level of small bowel. But specificity is very high as well.
Concerning lesion at the level of the retro cervical area, we can clearly identify deep infiltrating endometriosis affecting the uterosacral ligaments that is the most common affected area in the posterior compartment, and by using the sacral ligament as an anatomical reference, so we can also distinguish that lesion that affects the parameter that probably are the most important from a clinical and surgical point of view. In terms of surgical complexity, we recently published this paper in which we showed very high sensitivity and specificity in distinguished lesion at the level of retro insert of utero sacral ligament with the lesion extending to parametria. And this is of about most importance because that lesion are more likely to involve uter and concerning lesion affecting the lateral perimeter. We should always pay attention to the proximity to the uter if the uter is in contact with the lesion or completely involved with or restricted by the lesion itself.
And the advice is always to have a look at the kidney of the patients because sometimes the kidney loss can be silent, so it's of atmos importance to provide that information by extension to the anterior parametal area is very rare. Probably the highest challenge for surgeons approaching deep infiltrating endometriosis is the extension to dorsal parameter. That means the area in which the majority of narrow pelvic fibers run. And our challenge now and our latest challenge from sonographer points of view is not only to predict the area in which nerves runs, but to see the nerves. This is a very nice paper provided by the Hungarian group who described the visual ultrasound, graphic visualization of sacral nerve roots and that are pictures made by me just immediately after reading the, so it means that it's really absolutely feasible. And since curiosity moved the words, this is what we need immediately after to go to the OR and try and to manage to identify by ultrasound in a surgical guided manner, the identification of the left hypogastric nerve.
Because if we can see nerves at the level of the pelvic sidewall, we are sure that we can see nerves that are even closer to the our prob. So in conclusion, ultrasonography advantages compared to MRI. It has similar overall diagnostic accuracy, expert tense. It's dynamic examination. It allows the so-called tenderness guided so we can put together clinical information and guide our examination on the basis of the pain felt by the patients. We could get immediate results and adjust the patient's management according to our findings. It's cost effective and it can be also performed ly basis. Thank you very much for your attention.
