Transvaginal sonography and surgical findings in the diagnosis of endometriosis individuals: A cross-sectional study

Abstract Background Endometriosis is a challenging gynecological disease and a debilitating condition that profoundly affects the individual's quality of life. Besides pathological confirmation, diagnostic laparoscopy has been internationally accepted as the standard method to identify the accurate mapping of endometriosis. Transvaginal sonography (TVS) is the first non-invasive imaging modality to estimate the severity of endometriosis. Objective This study aimed to evaluate the accuracy of TVS in affected women compared with surgical findings. Materials and Methods This retrospective cross-sectional study surveyed 170 women with deep infiltrating endometriosis (DIE) referred to the endometriosis part of the Avicenna Infertility Center, Tehran, Iran and they underwent TVS followed by laparoscopy. Recorded data of individuals under study in the medical database system were reviewed. Finally, the agreement rate was calculated for ultrasound reports and intraoperative (IO) findings regarding ovarian endometrium, ovarian adhesion, involvement of cul-de-sac, rectovaginal septum, and bowel and ureter. Results 170 women with DIE entered the study. The agreement of TVS and IO findings were 86.76% for left ovarian endometriosis and 70.86% for right ovarian endometriosis, 93.90% for left ovarian adhesion, and 88.90% for right ovarian adhesion, 88.90% for a cul-de-sac, and 84.82% for bowel nodules. The findings, based on a laparoscopic assessment of the pelvic floor, were completely compatible with ultrasound reports (100%). Conclusion TVS allows a preoperative evaluation in planning the surgical policy associated. TVS is beneficial for dedicated mapping of DIE; thus, an expert radiologist can aid the surgeon in preoperative evaluation and IO management.


Introduction
Endometriosis is a challenging gynecological disease and a debilitating condition that profoundly affects individuals' quality of life.
"DIE is the presence of endometriosis implants that penetrate the retroperitoneal space for a distance of 5 mm or more (3)(4)(5). DIE can involve the Douglas pouch, the rectovaginal septum, the intestine, the anterior pouch, and the uterosacral ligaments. Assessment of this disease is difficult only by physical examination (4)(5)(6)(7). Transvaginal sonography (TVS) is currently considered a fundamental non-invasive diagnostic method to evaluate the extent of DIE within the pelvis and facilitate the choice of a safe and adequate surgical or medical treatment (7-9)". The most common presentations include pelvic pain, infertility, dysmenorrhea, dyschezia, and urinary manifestations. However, the non-specific symptoms of DIE often result in a missed diagnosis or delayed approach (1). DIE mostly appears as a multifocal disease in some locations with a higher likelihood of involvement, such as the bowel, vagina, urinary system, etc. (2).  (6). It is often considered the first non-invasive imaging modality to estimate the severity of endometriosis (8,9).
This research aims to evaluate the accuracy of pre-surgical TVS in women with endometriosis and to compare the reports with surgical findings reports.

Materials and Methods
This if any uncertainty about the mapping existed.
All tissue specimens were studied in the same pathological laboratory following a laparoscopy.
To assess the diagnostic agreement between surgery and ultrasound, we categorized the mapping results of both methods identically: 3-layer categorization for ovarian cysts (no cyst, non-endometriotic cyst, OMA) and cul de sac (not involved, partially obliterated, and completely obliterated) and dichotomous categorization (involved, not involved) for ovarian adhesion, tubes, ureter, and bowel.    Table III Table IV shows the ultrasound and surgery of the bowel with .84.82% agreement (K = 0.53).     as endometriosis (18)(19)(20).

Statistical analysis
The retrospective study on 420 cases has detected the same results as ours in terms of fallopian tubes and all other anatomical lesions (20).
Several studies agree with our results in investigating bowel endometriosis by TVS and its agreement with IO findings (21)(22)(23)(24) can safely be inferred that these will be present at the surgery without prior confirmative imaging.
In the study in Iran (17) (14)." In this study, bowel DIE had 7.1% sensitivity and, specificity of 98.87%. In the study of Albozi et al. (7). "The TVS, transrectal sonography, and magnetic resonance imaging observed a sensitivity of 100% for the detection of ureteral DIE.
Another study using TVS as the first-line screening imaging technique suggested another study (10).
It was unclear as to why some sensitivities were lower than others. In the normal pelvis, the uterosacral ligaments were not seen with ultrasono, which may account for some of the poor accuracies encountered in this region (10,7)."

Conclusion
In conclusion, TVS allows a precise preoperative evaluation in planning the right surgery policy associated with the improvement in the capability of surgical techniques. This confirms that an expert radiologist can aid the surgeon in the preoperative evaluation and IO management.