Transvaginal ultrasound for diagnosis of deeply infiltrating endometriosis

Deeply infiltrating endometriosis is the clinical form of the disease that is generally associated with conditions of more intense pain and may require more complex surgical management, consequently resulting in greater risks to the patient. In recent years, various investigators have confirmed the usefulness of methods such as magnetic resonance imaging (MRI), transrectal ultrasound and transvaginal ultrasound (TVUS) for the diagnosis of deep endometriotic lesions. The objectives of the present study are to describe the method used to perform TVUS for the detection of deeply infiltrating endometriosis, and to discuss the clinical benefits that the data obtained may offer clinicians providing care for patients suspected of having this type of endometriosis.     

Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification

Objective

To use the ENZIAN classification for preoperative estimation of laparoscopic operating time in patients with deeply infiltrating endometriosis (DIE).

Study design

Retrospective study of women with DIE (n = 151) who underwent laparoscopic surgery.

Results

151 of 470 patients had DIE (n = 205 lesions) exclusively in compartments A (rectovaginal septum, vagina), B (sacrouterine ligament to the pelvic wall) and C (rectum, sigmoid colon). These laparoscopically treated lesions were used to calculate a model for estimating operating time for DIE, assuming complication-free procedures (overall significance for model's predictive power: P < 0.001). The error of estimation for the operating time prediction is 0 ± 35.35 min (mean ± SD; range −83 to +117 min). The actual operating time for all operations was 109.32 ± 74.38 min (mean ± standard deviation).

Conclusions

Using a model for predicting operating time based on the ENZIAN classification enables resources to be planned more precisely in surgery management. Patients with DIE can also be given more precise information regarding the expected operating time.     

超声检查对深部浸润型子宫内膜异位症诊断价值的荟萃分析

目的 系统评价超声诊断深部浸润型子宫内膜异位症(内异症)文献的质量,并荟萃分析超声检查对深部浸润犁内异症病灶诊断的准确性.方法 采用计算机和手工检索方法,全面收集1966-2009年关于深部浸润型内异症的超声检查诊断性试验的文献,并根据诊断准确性研究的质量评价量表(QUADAS)评价符合纳入标准的文献质量,用Meta-disc软件对直肠超声(TRUS)、阴道超声(TVUS)、直肠内镜超声(EUS)的敏感性、特异性、阳性似然比(+LR)、阴性似然比(-LR)、诊断性试验比值比(DOR)等进行合并分析和异质性检验,对无异质性的文献绘制综合受试者工作特征(SROC)曲线.结果 共纳入符合标准的文献15篇,均为英文文献.QUADAS中有10项条目的 符合率均超过60%;第11项条目"是否是在不知道待评价试验的结果下进行参考标准结果的判读"的符合率为46.7%(7/15);无一篇研究报道了第13项条目"是否报道了无法解释和(或)中间试验的结果".通过阈值效应分析没有发现研究的异质性.TRUS的敏感度、特异度、+LR、-LR、DOR分别为0.925、0.986、30.036、0.107、299.25;TVUS为0.799、0.944、11.972、0.187、69.126;EUS为0.635、0.928、8.022、0.320、39.606;EUS的SROC曲线下面积为0.9479,略高于TVUS的0.9246.结论 TRUS、TVUS和EUS均显示了对深部浸润型内异症较好的诊断价值.本系统评价所纳入15篇文献的偏倚主要来自参考标准判读时未实施盲法,存在变异的可能性较大.     

后盆腔深部浸润型子宫内膜异位症的临床病理特点及腹腔镜手术治疗效果

目的 探讨后盆腔深部浸润型子宫内膜异位症(PDIE)疼痛症状的特点、临床分型和腹腔镜手术治疗效果.方法 以2003年2月至2008年2月在北京协和医院就诊、经腹腔镜手术和病理检查证实为PDIE的176例患者为研究对象,以179例非PDIE的内异症患者为对照,PDIE患者按照是否侵犯阴道穹隆或直肠分为单纯型(144例)、穹隆型(18例)和直肠型(14例);分析患者的临床病理资料.结果 PDIE患者91.5%(161/176)有不同程度的痛经,中度痛经(36.4%,64/176)、重度痛经的比例(42.0%,74/176)均高于非PDIE患者,痛经风险的OR值为6.73(95% CI为3.66～12.40).PDIE患者中,慢性盆腔痛的发生率(33.0%,58/176)、性交痛的发生率(45.5%,80/176)、肛门坠胀的发生率(58.0%,102/176)及大便痛的发生率(22.7%,40/176)均高于非PDIE患者,其OR值分别为1.90、3.09、3.11和4.90(95% CI分别为1.17～3.05、1.94～4.92、2.10～4.81和2.07～8.11).3种类型PDIE患者中,直肠型患者大便痛的发生率(50.0%)增加;穹降型患者发生性交痛(72.2%)和肛门坠胀(88.9%)的比率也高于另外两种类型;分别比较,差异均有统计学意义(P<0.05).直肠型PDIE患者腹腔镜手术时间[(82±31)min]、术后住院时间[(7.7±2.1)d]明显延长;穹隆型患者术中出血量增加[(99±24)ml];分别比较,差异均有统计学意义(P<0.01).3种类型PDIE患者中,直肠型腹腔镜手术完全切净率(28.6%)最低,其次为穹隆型(83.3%),单纯型达到了95.1%.3种类型PDIE的手术有效率分别为99.3%、94.4%、100.0%,分别比较,差异无统计学意义(P>0.05).手术切净程度是影响术后疼痛缓解时间的主要因素(P<0.05).结论 PDIE与各种子宫内膜异位症疼痛症状的关系密切,不同类型的PDIE腹腔镜保守性手术后能获得较满意的疼痛缓解,术后疼痛缓解时间与手术切净程度相关.     

深部浸润型子宫内膜异位症复发处理

复发是子宫内膜异位症（endometriosis,EM,内异症）临床诊治中常见、难以处理、需管理的一项重要问题。深部浸润型内异症（deeply infiltrating endometriosis,DIE）经彻底切除后很少复发,前次手术残留的病灶被认为是复发的主要原因。复发的患者盆腔粘连严重、病灶侵入深,手术并发症多,为再次手术增加了极大的难度,对于术者的技术水平要求则更高。因此,二次手术必须基于细致的风险、收益评估方可实施。加强术前及术后各个环节治疗方案的评估,强调有计划的终身管理。     

Major and minor complications after resection without bowel resection for deeply infiltrating endometriosis

Purpose

To analyze major and minor complications following surgery for deeply infiltrating endometriosis including long-term impairment of intestinal, bladder, and sexual function.

Methods

Patients who had undergone resection for deeply infiltrating endometriosis without anterior rectal resection between 2001 and 2011 were included (n?=?134). Clinical and surgical data, as well as minor and major complications, were recorded. A questionnaire was sent to the patients and to a healthy control group (n?=?100).

Results

Major complications occurred in 3.7% and minor complications in 12.7% of the patients. Surgical revision was necessary in five cases. The questionnaire response rate was 66.4%, with a mean follow-up period of 75.6 months. Weak urinary flow was reported by 26.4% of the patients; a feeling of residual urine by 16.1%; constipation by 13.5%; more than one bowel movement/day by 16.9%; insufficient lubrication during intercourse by 30.3%. The findings for weak urinary flow, feeling of residual urine, and insufficient lubrication differed significantly from the control group. Subgroup analysis did not identify any statistical associations between questionnaire responses and dyspareunia or dysmenorrhea as reasons for surgery, or previous endometriosis surgery in the patient’s history.

Conclusions

The major and minor complication rates were consistent with or lower than the literature data. Few studies have investigated complication rates associated with treatment for endometriosis in the sacrouterine ligaments and/or the rectovaginal septum. The high rates of impaired bladder function and sexual function after endometriosis surgery, as well as inadequate data, make further prospective studies on this topic necessary.

     

Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis

STUDY OBJECTIVE: To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. MEASUREMENTS AND MAIN RESULTS: Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). CONCLUSION: High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term "deep endometriosis infiltrating the rectovaginal septum" is generally incorrect in the true anatomic sense.     

Enterocele as a consequence of laparoscopic resection of deeply infiltrating endometriosis

Laparoscopic excision of deeply infiltrating endometriosis in the cul-de-sac or the rectovaginal septum by means of electrosurgery or laser is performed frequently. Little is known about the long-term results or complications of this surgery. We suggest that enterocele could be a complication of the procedure. A patient developed a large enterocele 3 years a laparoscopic excision of a deep endometriotic nodule with resection of the uterosacral ligaments. We question whether routine preventive measures should not be taken after excision of a deep endometriotic nodule from the rectovaginal septum.     

Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis

Objective

To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) findings relative to surgical presence of deeply infiltrating endometriosis (DIE).

Methods

This prospective study included 92 women with clinical suspicion of DIE. The MR images were compared with laparoscopy and pathology findings. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for diagnosis of DIE were assessed.

Results

DIE was confirmed at histopathology in 77 of the 92 patients (83.7%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI to diagnose DIE at each of the specific sites evaluated were as follows: retrocervical space (89.4%, 92.3%, 96.7%, 77.4%, 90.2%); rectosigmoid (86.0%, 92.9%, 93.5%, 84.8%, 89.1%); bladder (23.1%, 100%, 100%, 88.8%, 89.1%); ureters (50.0%, 100%, 95.5%, 95.7%); and vagina (72.7%, 100%, 100%, 96.4%, 96.7%).

Conclusion

MRI demonstrates high accuracy in diagnosing DIE in the retrocervical region, rectosigmoid, bladder, ureters, and vagina.     

腹腔镜治疗深部浸润型子宫内膜异位症临床疗效61例分析

目的探讨腹腔镜手术治疗深部浸润型子宫内膜异位症的疗效和安全性。方法对北京大学第一医院收治的61例深部浸润型子宫内膜异位症患者临床资料进行分析。结果 61例手术均在腹腔镜下完成,无严重手术并发症。随访55例(随访率90.2%),平均随访时间42.7个月(12～74个月)。术后痛经缓解率分别为1年53.1%、2年51.1%、3年66.7%,与术前相比较差异均有统计学意义(P0.001)。但非经期下腹痛、肛门或直肠痛和性交痛与术前相比,差异无统计学意义。29例有生育要求者13例妊娠(44.8%);其中8例合并不孕症者4例妊娠(50%)。结论腹腔镜治疗深部浸润型子宫内膜异位症安全有效。     

Magnetic resonance imaging and endometriosis: deeply infiltrating endometriosis does not originate from the rectovaginal septum

The goal of this study was to describe the magnetic resonance (MR) imaging signs of deeply infiltrating endometriosis (DIE) lesions and above all to find out if MR imaging can pinpoint the location of these lesions. We made a retrospective study of 8 patients presenting with histologically proven DIE lesions. The MR imaging results were compared with intraoperative findings. Nodules revealed on T1-weighted images as isointense to myometrium with hyperintense spots remained visible on the fat-suppressed spin echo images. When there was no rectal involvement, the T1- and T2-weighted images showed a hypointense transition area between the nodule and the rectum. The DIE nodules were in identical locations in every case, lying below the torus uterinum, level with the posterior vaginal fornix and the upper third of the posterior vaginal wall. Without exception, the DIE nodules were located above the upper edge of the rectovaginal septum, with the latter appearing fine and regular with no image of any nodule. Our MR imaging results suggest that DIE lesions do not originate from the rectovaginal septum.