Diagnosis of endometriosis of the rectovaginal septum using introital three-dimensional ultrasonography

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1 Diagnosis of endometriosis of the rectovaginal septum using introital three-dimensional ultrasonography Maria Angela Pascual, M.D., Ph.D., a Stefano Guerriero, M.D., b Lourdes Hereter, M.D., a Pedro Barri-Soldevila, M.D., a Silvia Ajossa, M.D., b Betlem Graupera, M.D., a and Ignacio Rodriguez, B.Sc. c a Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, University of Barcelona, Barcelona, Spain; b Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; and c Unit of Biostatistics, Institut Universitari Dexeus, University of Barcelona, Barcelona, Spain Objective: To evaluate the diagnostic accuracy of introital three-dimensional (3D) transvaginal sonography for preoperative detection of rectovaginal septal endometriosis. Design: Ultrasonographic results were compared with surgical and histologic findings. Setting: University Department of Obstetrics and Gynecology. Patient(s): This prospective study included 39 women with suspected rectovaginal endometriosis. Intervention(s): All patients underwent 3D transvaginal sonography for the evaluation of the rectovaginal septum, before undergoing laparoscopic radical resection of endometriosis. Rectovaginal endometriosis was defined as hypoechoic areas, nodules, or anatomic distortion of this specific location. Main Outcome Measure(s): Sensitivity, specificity, and likelihood ratios (positive or negative) were calculated with 95% confidence intervals (CIs). Result(s): Surgery associated with histopathologic evaluation revealed deep endometriosis in the rectovaginal septum in 19 patients. The specificity, sensitivity, positive likelihood ratio, and negative likelihood ratio were 94.7% (95% CI, 78.6% 99.7%), 89.5% (95% CI, 73.3% 94.5%), 17.2 (95% CI, ), and 0.11 (95% CI, ), respectively. Conclusion(s): Introital 3D ultrasonography seems to be an effective method for the diagnosis of endometriosis of the rectovaginal septum and should be included in the preoperative evaluation of patients with clinical suspicion of deep endometriosis. (Fertil Steril Ò 2010;94: Ó2010 by American Society for Reproductive Medicine.) Key Words: Three-dimensional ultrasonography, rectovaginal endometriosis, diagnosis Deep invasive endometriosis is defined by the presence of endometriotic implants penetrating the retroperitoneal space for a distance of 5 mm or more. This disease involves several locations including the rectovaginal septum (1) but seems difficult to assess by physical examination only (2, 3). Preoperative evaluation is mandatory for the selection of different medical or surgical options and for the selection of an appropriate surgeon with sufficient experience in this kind of surgery (4). Transvaginal ultrasonography (US) should be considered the first-line procedure (5), but this technique seems to have controversial results in the diagnosis of deep endometriosis in some of the locations. As a matter of fact, some authors have reported a sensitivity of 30% in the rectovaginal septum location (6) although more encouraging results have been obtained by other authors using modified techniques (3, 7 9). In the last few years, the lower part of the pelvis has been studied by urogynecologists using three-dimensional (3D) introital US (10 12), but until now no studies have evaluated the role of this new technique in the identification of deep endometriosis of the rectovaginal septum. The aim of this study was to evaluate the Received January 11, 2010; revised February 22, 2010; accepted February 23, 2010; published online March 31, M.A.P. has nothing to disclose. S.G. has nothing to disclose. L.H. has nothing to disclose. P.B.-S. has nothing to disclose. S.A. has nothing to disclose. B.G. has nothing to disclose. I.R. has nothing to disclose. Reprint requests: Stefano Guerriero, M.D., Department of Obstetrics and Gynecology of the University of Cagliari, Ospedale San Giovanni di Dio, Via Ospedale 46, 09124, Cagliari, Italy (FAX: ; gineca.sguerriero@tiscali.it). diagnostic accuracy of introital 3D-US in the identification of rectovaginal septum endometriosis. MATERIALS AND METHODS This prospective study involved a series of 39 consecutive patients with clinically suspected endometriosis on the basis of patient history of pelvic pain and/or clinical examination and undergoing surgery at the Department of Obstetrics, Gynecology, and Reproduction at the Instituto Universitario Dexeus of Barcelona, from January 2008 through July Diagnosis of rectovaginal endometriosis was proved histologically for each patient. This observational study protocol was approved by our Institutional Review Board. All patients first underwent a two-dimensional (2D) B-mode transvaginal US examination with use of a standard US machine (Aplio-50 SSA-700; Toshiba Medical Systems, Tokyo, Japan, or Sonoline Antares; Siemens Medical Systems Inc., Erlangen, Germany) equipped with a vaginal multifrequency probe. After scanning the uterus and adnexal regions, attention was paid to the ovaries, pouch of Douglas, vesicouterine pouch, and uterosacral ligament. Transvaginal US scans were carried out by three experienced examiners (M.A.P., L.H., B.G.). All participating patients then were informed that an additional 3D-US examination would be performed to obtain further information regarding the rectovaginal septum. Images were obtained with the Voluson 730 Expert and E8 (GE Healthcare, Milwaukee, WI), fitted with a transvaginal multifrequency ( and MHz respectively) transducer /$36.00 Fertility and Sterility â Vol. 94, No. 7, December doi: /j.fertnstert Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

FIGURE 1 (A) The drawing shows the anatomic structures visualized by 3D transperineal US in a sagittal plane (symphysis pubis, urethra, neck bladder, vagina, and rectum).

R ¼ rectum; V ¼ vagina; B ¼ bladder; U ¼ urethra; S ¼ symphysis pubis. FIGURE 2 (A) Schematic cross-section view of the female pelvic floor.

2 FIGURE 1 (A) The drawing shows the anatomic structures visualized by 3D transperineal US in a sagittal plane (symphysis pubis, urethra, neck bladder, vagina, and rectum). The multiplanar reconstruction of the sagittal acquisition allows visualization of rectovaginal septum (oval area). (B) Sagittal plane of pelvic floor as visualized by 3D transperineal US (oval area). R ¼ rectum; V ¼ vagina; B ¼ bladder; U ¼ urethra; S ¼ symphysis pubis. FIGURE 2 (A) Schematic cross-section view of the female pelvic floor. The area in the circle represents the rectovaginal septum as shown by 3D imaging. (B) Axial rendering volume of the pelvic floor. The image shows the urethra, vagina, and rectum. The rectovaginal septum is delimited by vagina and rectum. P ¼ pubis; U ¼ urethra; V ¼ vagina; R ¼ rectum; OE ¼ obturator externus; OI ¼ obturator internus; LA ¼ levator ani. Introital 3D-US examinations were performed with the transducer placed on the perineum. The transducer was placed quite firmly against the symphysis pubis without causing significant discomfort. To acquire a correct volume, the symphysis pubis, urethra, vagina, and rectum should be visualized in the same image (Fig. 1A and B). Gain is adjusted and focal area is set to the region of interest with the sweep angle set at 90 degrees (Voluson 730 Expert) or 120 degrees (Voluson E8). Volume acquisition lasted <1 minute. This produced a multiplanar image showing the symphysis pubis, urethra and bladder neck, vagina, and rectum in three planes: longitudinal, transverse, and coronal (Fig. 1A and B). When the volume acquisition was completed, the data file was sent via Digital Imaging and Communication in Medicine (DICOM) to a personal computer and stored to be analyzed with use of the appropriate software (4Dview 5.0; GE Healthcare). All 3D volumes were acquired by three different operators (L.H., B.G., M.A.P.) using the same scanning protocol. However, stored 3D volumes were analyzed by just one examiner (L.H.). When 3D data were opened, images were displayed in three orthogonal planes and reviewed by using multiplanar navigation and the render mode available in the 4Dview version 5 (Fig. 2A and B). By 3D-US, deep endometriosis implants were suspected by the presence of hypoechoic areas, nodules, or anatomic distortion of this specific location (Fig. 3) with use of render mode in the coronal plane obtained after multiplanar navigation. All patients underwent surgery within 1 month after 3D evaluation. The surgical procedure is described in detail as follows. Laparoscopic approach was made through the umbilicus with the use of a Veress needle and an 11-mm trocar. Accessory trocars were placed under visual control in the left iliac fossa (5 mm), midline between umbilicus and pubis (5 mm), right iliac fossa (12 mm), and right paraumbilical (5 mm). The key to this type of surgery is to work from healthy to damaged tissue. This centripetal approach allows the surgeon to identify pelvic organs and separate them from endometriotic tissue. All endometriotic foci are removed. The procedure was started by the eventual adnexal adhesiolysis and temporary suspension to the abdominal wall with a 2/0 silk suture. In case parametrial endometriosis is present, a full broad ligament opening and eventual uterine artery ligation might be needed to remove the damaged tissue. Bilateral opening of the pararectal fossa was performed until the affected area was achieved. A rectal and vaginal probe was placed to expose the rectovaginal septum. Cautious dissection was made until the rectum was divided fully from the vagina. Depending on the possible rectal infiltration, the node was left attached to the vagina or the rectum. In case of posterior vaginal fornix infiltration, a partial colpectomy and suture need to be performed. In case the rectal infiltration exceeded 2 cm in diameter, or clear signs of rectal constriction were detected, rectal resection was advised. The rectum was sectioned in healthy tissue with one or two 2762 Pascual et al. Techniques and instrumentation Vol. 94, No. 7, December 2010

FIGURE 3 Three-dimensional multiplanar reconstruction with the render mode of the coronal plane shows an endometriotic nodule on the left of the rectovaginal septum, between the rectum and vagina

3 FIGURE 3 Three-dimensional multiplanar reconstruction with the render mode of the coronal plane shows an endometriotic nodule on the left of the rectovaginal septum, between the rectum and vagina (arrows). loads of mono-use stapler. A 3- to 5-cm minilaparotomy was performed, and the rectal stump was exposed and sectioned. The rectal probe of the endoanal stapler was then placed, the rectum reinserted in the abdominal cavity, and the laparotomy closed. Rectal anastomosis was made with the endoanal stapler under laparoscopic control. If the conservative option of the rectum was decided on, local full resection of the node was performed. In case the bowel lumen was opened, a transversal suture with 3/0 Vicryl (Ethicon, Sommerville, NJ) suture was performed. In both cases, rectal integrity was checked by filling the pelvis with saline solution and anal injection of air. If a leakage was detected, reinforcement of the suture was mandatory, and, if optimal suturing was not achieved, a temporary ileostomy was advised. Staging of the disease and scores were performed with use of the American Fertility Society (AFS) classification (13). The findings at 3D-US were compared with the findings at surgery with histopathologic confirmation of presence of endometriosis. Sensitivity, specificity, and likelihood ratios (LRþ or LR-) were calculated with 95% confidence intervals (CIs), according to the Statement for Reporting Diagnostic Accuracy Studies (STARD) (14). The calculation of sample size is not mandatory in a diagnostic study on the basis of STARD guidelines. Likelihood ratios were used because they are not affected by the prevalence of disease in the population studied (14). RESULTS We included 39 women in the study. The mean age (SD) of the study population was years, ranging from 25 to 44 years. The indication for surgery was clinically suspected endometriosis on the basis of patient clinical examination associated with pelvic pain in all 39 patients, of whom 15 patients had associated infertility. All patients reported the presence of dyspareunia and/or dysmenorrhea. All 39 had previous treatment for persistent pelvic pain with medications estroprogestins and/or GnRH agonist and nonsteroidal antiinflammatory drugs for at least 1 year. In 38 patients out of 39 the volume acquisition by 3D-US allowed a good multiplanar analysis of the rectovaginal septum; in only one case the volume quality was not adequate to be reelaborated because of a poor visualization of the rectum. This case was not considered in the statistical analysis. Fertility and Sterility â 2763

4 Surgery associated with histopathologic evaluation revealed deep endometriosis in the rectovaginal septum in 19 patients. In these patients the mean (SD) AFS score was (stage I: 5 patients, 12.8%; stage II: 4 patients, 10.3%; stage III: 17 patients, 43.6%; stage IV: 13 patients, 33.3%). The 2D-US showed endometriosis of the ovaries in 38 patients (97%) and the pouch of Douglas in 23 patients (59%). We distinguished endometriosis of the pouch of Douglas as infiltration of the posterior wall of the uterus and endometriosis of the rectovaginal septum as infiltration of the posterior wall of the vagina and the anterior rectal wall (Fig. 2). In all the patients included in the study, 2D-US completely missed the presence of endometriotic nodules in this specific location. Of the 20 patients considered negative by 3D introital US, 18 were confirmed as negative, and in 2 patients endometriosis of the rectovaginal septum was present. Of the 18 patients suspected to present deep endometriosis by 3D-US, 17 were confirmed by laparoscopy. In one patient with diagnosis of rectovaginal endometriosis, no pathologies were found at surgery. Using 3D-US we obtained a specificity of 94.7% (95% CI, 78.6% 99.7%) with a sensitivity of 89.5% (95% CI, 73.3% 94.5%) associated with a very high kappa value of 0.84 (95% CI, ). Positive LR was 17.2 (95% CI, ), and negative LR was 0.11 (95% CI, ), both indicating a good to excellent test. The pretest probability of rectovaginal involvement of deep pelvic endometriosis in our population was 50%, and this probability of disease rose to 94% when the test was positive and decreased to 10% when the test was negative. DISCUSSION Introital 3D-US seems to be an effective means of detecting endometriosis of the rectovaginal septum and should be included in preoperative evaluation in patients with clinical suspicion of rectovaginal endometriosis. To the best of our knowledge, this is the first prospective study about introital 3D-US and deep endometriosis. As suggested by Downey et al. (15), 3D-US has at least three advantages over 2D-US: [1] it seems to be highly reproducible, and the image can be reconstructed after a single sweep of the ultrasound beam across the target; [2] it may allow unrestricted access to an infinite number of viewing planes; and [3] stored 3D volumes can be reassessed and compared by the same or different examiners over time. In the diagnosis of deep endometriosis, as suggested by Guerriero et al. (16), the first advantage can be very useful to correctly locate the lesions in the pelvis evaluating the spatial relationship with other organs. The second characteristic may allow an evaluation even after the first acquisition to further study the involvement of the ureter or the bowel. The third characteristic may be relevant for monitoring the effect of medical therapies over a period of time (17). According to Raine-Fenning et al. (18), 3D-US improves spatial orientation by providing the observer with a range of different displays of the images in the three orthogonal planes. Any of these images can be selected and rotated or scrolled through in a fascinating virtual navigation also to obtain the coronal plane of the lesion, a plane practically impossible to obtain with use of 2D-US. As suggested by Guerriero et al. (16), the 3D image rendering could allow a better analysis of the nodule because this 3D reconstruction might make the irregular shapes and borders more evident. With use of 3D-US the surrounding tissues also can be identified easily. In the present study we observed nodules in a position in the pelvis usually impossible to evaluate with use of the simple 2D evaluation. For these reasons some studies report poor results of 2D in the evaluation of this specific location of deep endometriosis (6). In our study we could not compare 2D introital images with 3D introital data because of the impossibility of the 2D technique correctly evaluating the rectovaginal septum. The coronal plane and rendering mode of 3D introital allow an accurate evaluation of this anatomic region. Unfortunately 3D introital transvaginal US is not indicated to study peritoneal endometriotic lesions in the pouch of Douglas and/or uterosacral ligaments. Recently a study by Grasso et al. (19) compared two different imaging modalities, magnetic resonance and 3D-US, to evaluate the specific role in preoperative workup of deep infiltrating endometriosis. Unfortunately the authors did not explain how they performed the procedure, and the typical 3D findings used in the study are not described. For these reasons it is impossible to compare the two studies. Further studies in a larger population will be necessary to confirm these initial results, but, in our opinion, because of the diffusion of 3D machines in several departments of obstetrics and gynecology, this additional evaluation should be included in the diagnostic workup of patients with clinical suspicion of deep endometriosis in the rectovaginal septum. REFERENCES 1. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991;55: Chapron C, Liaras E, Fayet P, Hoeffel C, Fauconnier A, Vieira M, et al. Magnetic resonance imaging and endometriosis: deeply infiltrating endometriosis does not originate from the rectovaginal septum. Gynecol Obstet Invest 2002;53: Abrao MS, Goncxalves MO, Dias JA Jr, Podgaec S, Chamie LP, Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod 2007;22: Angioni S, Peiretti M, Zirone M, Palomba M, Mais V, Gomel V, et al. Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long term follow-up. Hum Reprod 2006;21: Piketty M, Chopin N, Dousset B, Millischer- Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod 2009;24: Bazot M, Thomassin I, Hourani R, Cortez A, Darai E. Diagnostic accuracy of transvaginal sonography for deep pelvic endometriosis. Ultrasound Obstet Gynecol 2004;24: Dessole S, Farina M, Rubattu G, Cosmi E, Ambrosini G, Nardelli GB. Sonovaginography is a new technique for assessing rectovaginal endometriosis. Fertil Steril 2003;79: Guerriero S, Ajossa S, Gerada M, D Aquila M, Piras B, Melis GB. "Tenderness-guided" transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain. Fertil Steril 2007;88: Guerriero S, Ajossa S, Gerada M, Virgilio B, Angioni S, Melis GB. Diagnostic value of transvaginal "tenderness-guided" ultrasonography for the prediction of location of deep endometriosis. Hum Reprod 2008;23: Tunn R, Petri E. Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. Ultrasound Obstet Gynecol 2003;22: Dietz HP. Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging. Ultrasound Obstet Gynecol 2004;23: Valsky DV, Yagel S. Three-dimensional transperineal ultrasonography of the pelvic floor: improving visualizationfornew clinicalapplicationsandbetterfunctional assessment. 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