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ABSTRACT
INTRODUCTION
Over the past decade, the use of transvaginal sonography (TVS) has improved the quality of non-invasive
assessment of patients with suspected pelvic pathologies.
With respect to endometriosis TVS has been shown
to be a highly sensitive tool for the detection of
ovarian endometriomas1 and is far superior to routine
clinical examination alone2,3 . Moore et al.1 systematically
reviewed 67 papers on the validity of TVS for the detection
of pelvic endometriosis, out of which seven fulfilled
the inclusion criteria and focused on TVS imaging of
ovarian endometriomas. The prevalence of the condition
ranged between 13 and 38%. Sensitivities, specificities and
positive (LR+) and negative likelihood ratios (LR) in six
studies using gray-scale ultrasonography ranged between
64 and 89%, 89 and 100%, 7.6 and 29.8 and 0.1 and 0.4,
respectively. The authors therefore concluded that TVS
should be regarded as a useful test for identifying cystic
ovarian endometriosis presurgically.
Recent studies also suggest that TVS could be an
accurate method for the detection of endometriosis in
extra-ovarian locations, i.e. uterosacral ligament involvement, endometriosis of the rectovaginal space, the pouch
of Douglas, the vagina, the urinary bladder and deep infiltrating endometriosis (DIE) of the rectosigmoid3 8 . Since
TVS is a readily available, cost- and time-effective diagnostic instrument when compared to other radiological
procedures such as computed tomography and magnetic
resonance imaging (MRI)9,10 , several investigators have
further examined the diagnostic value of TVS for the noninvasive detection of DIE infiltrating the bowel. The aim
Correspondence to: Prof. G. Hudelist, Department of Obstetrics and Gynaecology, Endometriosis and Pelvic Pain Clinic, Wilhelminen
General Hospital, Montlearstrasse 37, A-1160 Vienna, Austria (e-mail: gernot hudelist@yahoo.de)
Accepted: 7 October 2010
SYSTEMATIC REVIEW
Hudelist et al.
258
METHODS
The MEDLINE (19662010) and EMBASE (19802010)
databases were searched using the following search
strategy:
1. (pelvic or ovarian or deep infiltrating) near2 (mass or
cyst* or tumo* r)
2. ENDOMETRIOSIS in MeSH or 1 or BOWEL
ENDOMETRIOSIS
3. 2, not case reports, not review articles
4. with checktags female and human
5. with ULTRASOUND/all subheadings or TRANSVAGINAL/all subheadings or SONOGRAPHY
Abstracts of all studies identified were read and
manuscripts were then fully reviewed. In addition,
reference lists of all reviewed manuscripts were searched
for additional data. Study selection and assessment of
quality were performed independently by two reviewers
(G. H. and J. E).
Selection criteria
All studies included in the present review had to be
prospective and were required to involve both TVS examination and surgical exploration of the pelvis either
by laparoscopy or by laparotomy (as stated by Moore
et al.1 ). Scientific publications including case reports, studies on adenomyosis or extrapelvic endometriotic disease
as well as retrospective case series and review articles
were excluded. Studies reporting on pregnant women,
rectal ultrasound as the only examination and endoscopic
sonography were also excluded from this review. Patients
included in the studies presented with either subfertility
or symptoms suggestive of endometriosis.
According to the criteria of Moore et al.1 , studies were
considered to be of good quality when information on
recruitment of patients, blinding of ultrasound operators
and surgeons and data on the technical equipment were
provided. In order to define the stage and severity of
disease (i.e. the final endpoint of diagnosis), studies had
to describe the anatomical location of deep infiltrating
disease combined with histological confirmation of
endometriosis. Moore et al.1 considered that studies
missing one or two of these criteria were of moderate/poor
quality.
RESULTS
The initial implementation of the research strategy
revealed 188 studies relating to endometriosis and/or
adenomyosis and/or ovarian endometriosis diagnosed
by laparoscopy or laparotomy and/or ultrasonography.
Out of these only 51 papers specifically used TVS
and surgical exploration to diagnose DIE. Of these 51
papers, seven were excluded because they were case
reports or descriptive in nature. A further 18 papers
did not meet the inclusion criteria due to the fact
that they were review articles, despite the exclusion
of this article type in the primary search process.
Finally, three other publications included comments on
publications and were also excluded from the final
analysis, leaving 23 manuscripts for review3 5,7,8,18 35 .
Out of these 23 papers, 13 publications were excluded
due to methodological problems; three papers were
purely retrospective in nature18,27,28 ; four manuscripts
259
DISCUSSION
Endometriosis infiltrating the rectosigmoid can be
suspected in up to 922% of all women with proven
endometriosis36,37 . Symptoms of DIE involving the bowel
vary greatly, ranging from asymptomatic women with
extensive rectal involvement to patients with severe
dysmenorrhea and dyschezia38 . Treatment strategies
include hormonal preparations or surgical excision of
endometriotic nodules37,39 , but presurgical staging of
DIE is crucial for planning surgical treatment options.
The findings of our systematic review clearly suggest
that TVS is a highly valuable tool for the non-invasive
detection of DIE affecting the rectosigmoid. In addition to
sensitivities, specificities, PPVs, NPVs and test accuracies,
we recalculated all positive and negative LRs since these
reflect the diagnostic accuracy and the clinical usefulness
of a test independently of the prevalence of the study
condition in the study population1 . The prevalence of
Sonographers
blinded
No information
given
Sonographer
blinded
Radiologists
blinded
Sonographer not
blinded to PV
Sonographer
blinded
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Not described
Yes; as above
Sonographer
blinded
Not stated
Prospective
Sonographers
blinded
Prospective
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Consecutive; pain
and infertility
Recruitment;
cause for referral
194
200
92
134
88
90
104
32
142
30
81
48
63
75
39
23
54
17
47
22
Laparoscopic
visualization
Histology
Histology in 29
Histology
Reference
standard
TVS
TVS, MRI,
PV, RES
TVS, PV
TVS
TVS
Histology
Histology
Histology in 54
Histology
Histology
TVS,
Histology
RWC-TVS
TVS, MRI,
PV
TVS, MRI
TVS
TVS, RES
Patients with
Cases of
suspected
rectal/sigmoidal
endometriosis endometriosis Test
( n)
( n)
method
Good (12)
Moderate (13)
Good (12)
Good (12)
Good (11)
Good (12)
Moderate (10)
Poor (7)
Moderate (8)
Moderate (9)
Study quality
according to
Moore criteria
(QUADAS score)
MRI, magnetic resonance imaging; PV, per vaginam clinical examination; QUADAS, quality assessment of diagnostic accuracy of studies; RES, rectal endosonography; RWC, rectal water contrast;
TVS, transvaginal sonography.
Bazot et al.
(2009)20
Hudelist et al.
(2009)8
Goncalves et al.
(2010)23
Piketty et al.
(2009)31
Guerriero et al.
(2008)26
Valenzano
Menada et al.
(2008)33
Bazot et al.
(2004)3
Carbognin et al.
(2006)21
Abrao et al.
(2007)4
Bazot et al.
(2003)19
Study
260
Hudelist et al.
261
0.05 (0.010.31)
0.13 (0.060.28)
0.29 (0.140.61)
0.02 (0.000.13)
0.04 (0.010.3)
0.36 (0.230.57)
0.10 (0.050.20)
0.06 (0.020.16)
0.04 (0.010.17)
0.02 (0.010.10)
27.62 (9.0284.58)
4.8 (1.2618.31)
8.17 (3.1121.44)
26.29 (6.72102.83)
48.56 (15.81149.10)
Sensitivity (%)
Specificity (%)
LR+
LR
DOR
Prevalence (%)
PPV (%)
NPV (%)
LR+, positive likelihood ratio; LR, negative likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.
97
94
84
99
99
81
93
96
98
99
89
94
75
98
99
78
89
88
99
98
100
93
100
100
100
87
97
100
94
100
8/8 (100)
92/95 (97)
15/15 (100)
50/50 (100)
67/67 (100)
45/49 (92)
56/58 (97)
29/29 (100)
149/152 (98)
113/113 (100)
21/22 (95)
41/47 (87)
12/17 (71)
53/54 (98)
22/23 (96)
26/39 (67)
68/75 (91)
59/63 (94)
46/48 (96)
79/81 (98)
22/30 (73)
47/142 (33)
17/32 (53)
54/104 (52)
23/90 (26)
39/88 (44)
75/133 (56)
63/92 (68)
48/200 (24)
81/194 (42)
Bazot et al. (2003)19
Bazot et al. (2004)3
Carbognin et al. (2006)21
Abrao et al. (2007)4
Valenzano Menada et al. (2008)33
Guerriero et al. (2008)26
Piketty et al. (2009)31
Bazot et al. (2009)20
Hudelist et al. (2009)8
Goncalves et al. (2010)23
Study
Prevalence of
rectal/sigmoidal
endometriosis
(n (%))
Sensitivity
(n (%))
Specificity
(n (%))
PPV (%)
NPV (%)
Accuracy (%)
LR (95% CI)
262
ACKNOWLEDGMENTS
The authors want to thank Dr Simone Ferrero and MMag
Nadja Fritzer for their support and helpful advice. This
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