International Journal of Gynecology and Obstetrics

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1 International Journal of Gynecology and Obstetrics 118 (2012) Contents lists available at SciVerse ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: CINICA ARTICE Diagram to map the locations of endometriosis Ricardo Bassil asmar, Bernardo Portugal asmar, Claudia Pillar Department of Gynecology of Fluminense Federal University, Niteroi, Rio de Janeiro, Brazil article info abstract Article history: Received 4 November 2011 Received in revised form 9 February 2012 Accepted 20 arch 2012 Keywords: Classification Diagram Endometriosis apping Objective: To develop and test a visual map that corresponds practically and objectively to the anatomical areas affected by endometriosis. ethod: The study comprised 150 questionnaires concerning 10 clinical cases of endometriosis presented as a visual diagram that were distributed at 3 different scientific events, among 3 groups of 50 gynecologists. Data were analyzed to evaluate the diagram's ability to graphically represent the endometriosis sites. Results: After presentation at the first event, the rate of correct answers on the site of endometriosis was 84.7%; at the second event, after modifications implemented after feedback from the first event, the rate of correct answers was 97.4%; and at the third event, when all suggestions and modifications had been made, the rate was 99.7%. Conclusion: The diagram proposed to map the location of endometriosis lesions appears to be an adequate and effective instrument to represent the site of the disease, with correlation at almost 100% International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland td. All rights reserved. 1. Introduction Endometriosis affects about 10% of women of reproductive age. Its prevalence ranges from 30% 50% in women diagnosed as infertile [1 4]. The disease is defined by the presence of endometrial glands and stroma in ectopic sites [1,2,5]. Endometriosis is associated with variable clinical outcomes and presents an insidious and progressive evolution, interfering with the quality of life and daily activities of those affected [1,6 8]. The etiology and pathogenesis of endometriosis remain uncertain, including genetic, hormonal, and inflammatory aspects [2,8]. The Sampson theory, from 1927, which proposed retrograde menstruation as the trigger for endometriosis, is the most widely accepted theory [2]. Owing to gene expression involved in cell apoptosis, endometrial cells can survive in the peritoneal cavity. When activated macrophages are present, neoangiogenesis begins, leading to implantation and invasion of ectopic tissue, which is sustained and grows under estrogen stimulation [2]. From an anatomical and clinical viewpoint, endometriosis has 3 forms: peritoneal or superficial, ovarian, and deep infiltrative. ultiple forms can be present in one patient. The peritoneal form typically presents as pigmented or white, typical and atypical lesions throughout the surface of the peritoneum. Ovarian forms are characterized by the presence of chocolate cysts. The deep forms include lesions with larger-than-5-mm infiltrates that can involve pelvic and abdominal organs [5]. Corresponding author at: Department of Gynecology of Fluminense Federal University, Rua arques do Paraná 303, Niteroi, Brazil. Tel.: ; fax: address: ricardo@lasmar.com.br (R.B. asmar). One of the major challenges of making a diagnosis in women with suspected endometriosis is to assess the extent of the disease and its functional consequences for the pelvic or extra-pelvic organs. oreover, it is difficult to create a common language among specialists that allows standardized diagnosis and treatment [9]. The endometriosis classification system produced by the American Fertility Society, revised in 1985, has been helpful in documenting the disease, but it has serious limitations in clinical use for predicting prognosis and treatment of pain and infertility [10 12]. any researchers have suggested classifications of endometriosis, but there is still no validated system that meets clinical needs and pregnancy rates [10 14]. Choice of therapy depends on the symptoms of pelvic pain and infertility, the patient's goals, and the functional impairment assessed by clinical history, physical examination, and imaging [2]. ormone therapy and surgery are treatment options [2]. aparoscopy is considered the gold standard for diagnosis and offers a broader and more detailed view of the pelvic organs, reduced risk of infection and abdominal wall complications, shorter hospitalization with faster return to daily activities, and a higher likelihood of conservative surgery [2,6,15]. The decision on indication for surgery must take late diagnosis into account, and the first surgical approach must be the best possible to achieve the benefits and to reduce the risks of functional impairment [16]. oreover, some studies have shown that recurrence rates for endometriosis are 20% at 2 years, and 40% 50% at 5 years. For this reason, experts avoid incomplete resections and carefully evaluate the possibility of multifocality and multicentricity of lesions [6,15]. Since clinical data are essential for therapeutic management, mainly in complex surgeries, the topographic locations of lesions should be accurately and objectively recorded [17]. Information is crucial to determine the appropriate treatment, coordinating the actions of multidisciplinary clinical teams, and planning and obtaining the required management and financial resources for every patient. To /$ see front matter 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland td. All rights reserved. doi: /j.ijgo

2 R.B. asmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) be useful, clinical records must be clear and precise, organized and standardized, and easily understood by team members [18]. A visual diagram representing the sites affected by endometriosis may serve as a guide at the time of surgery and later during clinical follow up [17]. Several studies have described the most frequent locations of lesions and the trend toward multifocality, which must be taken into account when deciding upon management [17]. The aim of the present study was to develop a visual map corresponding to the anatomical areas affected by endometriosis in a practical and objective manner, to be included in patients clinical records and used in follow up. 2. aterials and methods The present study is a descriptive study of a case series. A total of 150 questionnaires concerning 10 clinical cases of endometriosis presented as visual diagrams were distributed during 3 scientific gynecology meetings held from arch to June, 2011, in Rio de Janeiro, Brazil. At each meeting, the questionnaires were handed out to 50 different gynecologists, who voluntarily accepted to participate in the study. All returned questionnaires were considered, including those that contained no answers or were incomplete. The study was not submitted to the ethics committee because it was not involved in the direct care of patients. The questionnaire requested open answers to questions concerning 10 different cases of endometriosis that had been provided by 10 specialists with extensive experience in treating the condition. Each clinical case was interactively presented to the participants using an endometriosis-mapping diagram. Before presenting the cases, an example of how the diagram worked was given, and the meaning of each abbreviation and the diagram's purpose were explained for 5 minutes. As the clinical cases were presented, the participants were asked to record the areas affected by endometriosis. Each participant had ANTERIOR BA(cm) VUS OVA( cm) OVA( cm) Central Around Distant SAN RECTU( cm) S D SIG( cm) APE CEC SAN Central EGEND POSTERIOR = cervix = uterus Around = vagina = retrocervical = rectovaginal septum = paracolpos/parametrium VUS = vesicouterine septum OVA = ovary = uterosacral ligament =round ligament Distant BA = bladder = ureter RET = rectum SAN = sacral nerves SIG = sigmoidcolon CEC = cecum APE = appendix Rectum penetration S = superficial = medium or muscular D = deep or mucosa Rectum height = low = medium = high Side Right eft Anterior Posterior Fig. 1. Diagram to map the anatomical areas affected by endometriosis.

3 44 R.B. asmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) minutes to look at the diagram representing the case and to write down where the endometriosis was located. During the presentation, some gynecologists raised questions and these were answered promptly and then noted down, thus generating data for future revisions of the diagram to improve its understanding and interpretation. At completion, all data were tabulated for individual participants and for the groups evaluated at different times. At the end of the third meeting, a total of 150 gynecologists, divided into 3 groups of 50, had completed the questionnaire. Each physician could list 38 endometriosis sites over the 10 clinical cases, totaling up to 1900 answers per group of 50 gynecologists. These data were analyzed to evaluate the diagram's ability to graphically and precisely represent the endometriosis sites. The answers were considered correct or incorrect. The first group of 50 physicians showed some difficulty in understanding the diagram (Fig. 1), which led to its modification by the addition of one further letter to the abbreviations representing the sites affected by endometriosis to indicate laterality. The central, peripheral, and distal involved areas of the uterus are represented by distinct patterns of colors. The sites represented in the diagram are the cervix and uterine body, uterosacral ligament, paracolpos, ovaries, round ligaments, vagina, rectovaginal septum, retrocervical nodule, vesicouterine pouch, ureters, rectum, sigmoid colon, bladder, appendix, sacral nerve, and cecum. Among the 10 clinical cases, 6 cases showed 4 affected sites each; 3 cases showed 3 affected sites each; and 1 case showed 6 affected sites. Involvement of the retrocervical area was described in 6 out of 10 clinical cases and of the paracolpos area in 5 cases; the other areas were involved less often (Table 1). The frequency of hits and errors was established in all 3 groups separately for each item and across all items, and the results of the 3 groups were compared. For the total frequency of hits in the different groups, the proportion test for K(3) samples was applied, assuming as the null hypothesis that the population proportions are equal, and as the alternative hypothesis that proportions among the 3 populations are not equal. As expected, the frequency was different in the last group tested. The confidence level was established at 1%, i.e. a significance of 0.01 with 2 degrees of freedom. The χ 2 value was calculated and compared with critical χ 2 values to determine whether the null hypothesis was supported. Participant data on sex, age, and experience with laparoscopy and other surgeries were collected. Based on these data, proportions, means, medians, standard deviations, coefficients of variation, and asymmetry indices were calculated. P value hypothesis testing was applied. Table 1 Sites of endometriosis in each of the 10 clinical cases. Site Cases Posterior vagina Uterus Retrocervical Right uterosacral ligament eft uterosacral ligament Right paracolpus eft paracolpos Right round ligaments eft round ligaments Right ovary eft ovary Right ureter eft Ureter Sigmoid colon Rectum Cecum Appendix Vesicouterine pouch Bladder Table 2 Characteristics of the 150 participating gynecologists. a Participants Group 1 Group 2 Group 3 P value (n=50) (n=50) (n=50) Age, y a 39.6± ± ± aparoscopic experience b 48 (96) 47 (94) 48 (96) Endometriosis experience b 32 (64) 36 (72) 44 (88) a Values are given as mean±sd and number (percentage). 3. Results Out of 150 questionnaires returned, only 5 had blank answers and these were interpreted as incorrect. The age of the participants ranged between 26 and 65 years. In the first group of 50 physicians, 16 (32%) were aged under 30 years, and 14 (28%) were over 50 years. In the second group, 15 (30%) were aged under 30 years, 14 (28%) were between 41 and 50 years, and 11 (22%) were over 50 years. In the third group, 12 (24%) were under 30 years and 15 (30%) were over 50 years. Of the 150 respondents, 84 (56%) were male. In both the first and second groups, 33 (66%) participants had less than 5 years of experience with laparoscopy, while 3 (6%) had more than 21 years of experience. In the third group, 23 (46%) physicians had less than 5 years of experience with laparoscopy, while 5 (10%) had more than 21 years of experience. The majority of gynecologists in all 3 groups responded that they had performed surgery for endometriosis: 64% (n=32) in group 1; 72% (n=36) in group 2; and 88% (n=44) in group 3. The third group of physicians comprised a more homogeneous population, exhibiting lower coefficients of variation compared with the other 2 groups for age range and years of experience with laparoscopy. owever, there were no significant differences in these features among the 3 groups (Table 2). The average number of correct answers in each of the groups is shown in Table 3. Proportion tests were calculated using these data, and the χ 2 value was The critical χ 2 value for α=0.01 and 2 degrees of freedom was 9.2. Since the calculated χ 2 value was higher than the critical value, the null hypothesis was rejected, i.e., the results analyzed differed among the groups. It was observed that group 3 had more correct answers than the other groups. When evaluating the sites of endometriosis separately, correct answers for retrocervical lesions were given by 86% of participants in group 1, 86% in group 2, and 100% in group 3. For sigmoid sites, correct answers were given by 80%, 100% and 97% of participants in groups 1, 2, and 3, respectively. For sites in the left ovary, the correct answers varied between 88.6% and 100%. In group 1, 13.3% of participants gave incomplete information about laterality in otherwise correct answers for ovarian sites. Table 3 Correct answers for site of endometriosis by group. Site Group 1 Group 2 Group 3 No. (%) No. (%) No. (%) Vagina 79 (79) 100 (100) 100 (100) Uterus 85 (85) 92 (92) 100 (100) Retrocervical 258 (86) 295 (86) 300 (100) Uterosacral ligament 132 (88) 146 (97) 150 (100) Paracolpos 214 (86) 250 (100) 250 (100) Round ligaments 81 (81) 92 (92) 100 (100) Ovary 174 (87) 197 (99) 200 (100) Ureter 83 (83) 96 (96) 100 (100) Sigmoid colon 120 (80) 150 (100) 146 (97) Rectum 220 (88) 243 (97) 250 (100) Cecum 42 (84) 47 (94) 50 (100) Appendix 44 (88) 50 (100) 50 (100) Vesicouterine pouch 39 (78) 45 (90) 48 (96) Bladder 38 (76) 49 (98) 50 (100) Total 1609 (84.7) 1852 (97.4) 1894 (99.7)

4 R.B. asmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) Site Fig. 2. Correct answers for site of endometriosis by group. The mapped area with the least correct answers in group 1 was the bladder (76%), followed by the vesicouterine pouch (78%); in groups 2 and 3, these rates varied between 90% and 100%. Clinical cases 8 and 10 included lesions in the mid- and high rectum and their size was given in centimeters; the hit rates varied between 88% and 100% in these sites in the 3 groups. owever, participants did not describe the size of these lesions in centimeters in 42% to 63.4% of otherwise correct answers. When lesions were located in the uterus, group 1 participants answered correctly in 85% of cases, group 2 in 92%, and group 3 in 100%. esions located in the paracolpos area were associated with hit rates varying between 86% and 100%. Ureteral lesions were identified by 83% to 100% of participants in the 3 groups. Separate correct rates for mid- and high rectum sites varied between 88% and 100% in all 3 groups, but in up to 63% of correct answers, the size of lesions in centimeters was not included. This may have resulted from too brief a presentation of the clinical cases, or it might indicate that participants did not consider the size of lesions to be an important piece of information. On the other hand, after including laterality, identification of sites improved; for example, the correct answers for lesions in the left ovary increased from 88.6% in group 1 to 100% in group 2. Correct answers for the vesicouterine pouch site increased from 78% in group 1 to 90% in group 2. Some other terms, such as vesicouterine septum and anterior bladder, were used by physicians in reference to the vesicouterine pouch, which might indicate a flaw in the uniformity of terminology; nevertheless, after modifications to the abbreviations, correct answers increased to 96% in group 3 (Fig. 2). 4. Discussion A graphic mapping system of areas affected by endometriosis can be used as the basis for therapeutic decision making and follow up of patients. The present study proposed a mapping diagram for everyday clinical practice, both at the initial approach before surgery and at follow up. The primary aim of the study was to verify whether this kind of presentation is reproducible and easily understood. The interactive method employed allowed us to detect some difficulties in the understanding of cases, which led to minor modifications in the abbreviations and inclusion of laterality indicators to improve the final version of the diagram. Diagram to ap Endometriosis Diagram to ap Endometriose Diagram to ap Endometriose Case B A (c m ) B A (c m ) 2 cm left ovarian endometriosis OVA ( 2cm) OVA ( 2cm) eft uterosacral ligament Right uterosacral ligament RET ( cm) S D RET ( cm) S D asmar asmar asmar Diagram to ap Endometriosis Case 3 cm right ovarian endometriosis Right uterosacral ligament B A (2 c m ) Diagram to ap Endometriose OVA ( 3 cm) Diagram to ap Endometriose BA(2 cm) OVA ( 3 cm) Retrocervical endometriosis Right round ligament endometriosis 2 cm bladder endometriosis 2 cm deep endometriosis in high rectum RET ( 2 cm) S D RET ( 2 cm) S D asmar asmar asmar Fig. 3. Diagrams representing two of the cases presented.

5 46 R.B. asmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) When comparing the correct answer and error rates among the 3 groups, a progressive increase in hit rates was observed, especially for the third group. This increase was statistically significant, and was most likely due to the modifications made after the first presentation of the diagram, which facilitated correspondence between the mapping information and the sites affected by endometriosis in each clinical case (Fig. 3). Another factor that contributed to better understanding was an indicator of lesion distribution within the affected area: central, peripheral, and distal. It is not known whether a longer duration of presentation of the clinical cases or more repetitions of the instructions for reading the mapping would decrease the number of blank answers. Another aspect to be considered is that some groups comprised heterogeneous elements, such as gynecologists who had less experience or who had not participated in endometriosis surgery. The analysis of the responses showed that the endometriosis mapping diagram is easily understood and can describe the location of the affected sites in an objective and clear way. It may prove to be a useful tool for gynecologists because it reproduces the clinical data and images, is helpful in management and follow up of endometriosis patients, and can act as a map for surgical purposes. It will be useful in patient's referred to an endometriosis specialist and could be used in multicenter studies and investigations. Considering that the sample size was small, further studies must be performed in different countries to validate the diagram. In conclusion, the diagram proposed to map the location of endometriosis lesions appears to be an adequate and effective instrument to represent the site of the disease. In this study, the correlation was almost 100%. Conflict of interest The authors have no conflicts of interest to declare. References [2] Nácul AP, Spritzer P. Current aspects on diagnosis and treatment of endometriosis [in Portuguese]. Rev Bras Ginecol Obstet 2010;32(6): [3] alis G, echsner S, Ebert AD. The diagnosis and treatment of deep infiltrating endometriosis. Dtsch Arztebl Int 2010;107(25): [4] Abrao S, Gonçalves O, Dias Jr JA, Podgaec S, Chamie P, Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. um Reprod 2007;22(12): [5] Fritel. Endometriosis anatomoclinical entities. J Gynecol Obstet Biol Reprod (Paris) 2007;36(2): [6] Roman. Guidelines for the management of painful endometriosis. J Gynecol Obstet Biol Reprod (Paris) 2007;36(2): [7] Borguese B, Vaiman D, de Ziegler D, Chapron C. Endometriosis and genetics: what responsibility for the genes? J Gynecol Obstet Biol Reprod (Paris) 2010;39(3): [8] Somigliana E, Vercellini P, Vigano' P, Benaglia, Crosignani PG, Fedele. Noninvasive diagnosis of endometriosis: the goal or own goal? um Reprod 2010;25(8): [9] engarda CV, Passos EP, Picon P, Costa AF, Picon PD. Validation of Brazilian Portuguese version of quality of life questionnaire for women with endometriosis (Endometriosis ealth Profile Questionnaire EP-30). Rev Bras Ginecol Obstet 2008;30(8): [10] Roberts CP, Rock JA. The current staging system for endometriosis: does it help? Obstet Gynecol Clin North Am 2003;30(1): [11] ornstein D, Gleason RE, Orav J, aas ST, Friedman AJ, Rein S, et al. The reproducibility of the revised American Fertility Society classification of endometriosis. Fertil Steril 1993;59(5): [12] Adamson GD. Endometriosis classification: an update. Curr Opin Obstet Gynecol 2011;23(4): [13] Coccia E, Rizzelo F. Ultrasonographic staging: a new staging system for deep endometriosis. Ann N Y Acad Sci 2011;1221:61 9. [14] Chvatal R, abelsberger A, Wurm P, Schimetta W, Oppelt P. Comparison of revised American Fertility Society and ENZIAN staging: a critical evaluation of classifications of endometriosis on the basis of our patient population. Fertil Steril 2011;95(5): [15] Golfier F, Sabra. Surgical management of endometriosis. J Gynecol Obstet Biol Reprod (Paris) 2007;36(2): [16] Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, et al. Complications after surgery for deeply infiltrating pelvic endometriosis. BJOG 2011;118(3): [17] Chapron C, Fauconnier A, Vieira, Barakat, Dousset B, Pansini V, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. um Reprod 2003;18(1): [18] arin F. ealth Information System: general considerations. J ealth Inform 2010;2(1):20 4. [1] Pugsley Z, Ballard K. anagement of endometriosis in general practice: the pathway to diagnosis. Br J Gen Pract 2007;57(59):470 6.

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