Bassem Gerges

Introduction: In 2024, an international consensus statement on non-invasive imaging techniques for the diagnosis of pelvic deep endometriosis was published, recommending transvaginal sonography as the first-line imaging modality because of cost, availability, and low impact on the environment. Despite the increasing body of evidence supporting the use of imaging in the preoperative diagnosis of endometriosis, there is a paucity of data to confirm patient awareness. The aim of this study was to use an online survey or questionnaire from patients to collect quantitative data regarding their awareness, exposure, and experience with preoperative imaging for the diagnosis of endometriosis. Methods: This was a cross-sectional study, based on an online, international survey completed by patients with self-reported endometriosis from multiple online endometriosis groups. The survey went live from November 2025 to March 2026 and consisted of women and gender-diverse individuals with self-reported endometriosis, with a minimum required number of 100 participants. Results: A total of 180 participants started the survey, of which 142 (78.9%) completed the exercise. The mean age of the participants was 31.6 [standard deviation (SD) 8.7] years, with a median time of endometriosis diagnosis of 2 years (interquartile range 1–5), of whom 99 (69.7%) had at least one surgery, with a mean number of surgeries of 1.8 (SD 1.2). The majority of participants were from Australia (66.2%), followed by Canada (16.9%), New Zealand (11.3%), and the United Kingdom (2.1%), and an equal number were from Brazil, India, the Philippines, and Spain (0.7% each). Overall, 53.5% of participants agreed that endometriosis can be diagnosed without surgery, while only 32.4% agreed that bowel endometriosis can be diagnosed before surgery. Of these, the percentages of participants who agreed that bowel endometriosis can be preoperatively diagnosed with ultrasound, magnetic resonance imaging, computed tomography, and colonoscopy were 32%, 35%, 15%, and 15%, respectively. The participants obtained knowledge about endometriosis investigations and treatments from various sources, including their gynecologists (71.8%), general practitioners (57%), fertility specialists (11.3%), family members (12%), friends (21.8%), social media (68.3%), and other sources (29.6%). Conclusion: There is a disparity between participant awareness in our study and the evidence in the literature regarding the availability and accuracy of preoperative imaging for the diagnosis of deep endometriosis, possibly due to the misinformation disseminated via social media .

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), the European Society of Human Reproduction and Embryology (ESHRE), the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence‐based and clinically relevant statements on the use of imaging techniques for non‐invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval.Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counseling and planning of surgical treatment strategies. © 2024 The Authors. Published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology, by Universa Press, by The International Society for Gynecologic Endoscopy, by Oxford University Press on behalf of European Society of Human Reproduction and Embryology, by Elsevier Inc. on behalf of American Association of Gynecologic Laparoscopists and by Elsevier B.V.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and International Deep Endometriosis Analysis (IDEA) group, the European Endometriosis League (EEL), the European Society for Gynaecological Endoscopy (ESGE), ESHRE, the International Society for Gynecologic Endoscopy (ISGE), the American Association of Gynecologic Laparoscopists (AAGL) and the European Society of Urogenital Radiology (ESUR) elected an international, multidisciplinary panel of gynecological surgeons, sonographers, and radiologists, including a steering committee, which searched the literature for relevant articles in order to review the literature and provide evidence-based and clinically relevant statements on the use of imaging techniques for non-invasive diagnosis and classification of pelvic deep endometriosis. Preliminary statements were drafted based on review of the relevant literature. Following two rounds of revisions and voting orchestrated by chairs of the participating societies, consensus statements were finalized. A final version of the document was then resubmitted to the society chairs for approval. Twenty statements were drafted, of which 14 reached strong and three moderate agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and society chairs and rephrased, followed by an additional round of voting. At the conclusion of the process, 14 statements had strong and five statements moderate agreement, with one statement left in equipoise. This consensus work aims to guide clinicians involved in treating women with suspected endometriosis during patient assessment, counselling, and planning of surgical treatment strategies.

STUDY QUESTION: Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis? SUMMARY ANSWER: The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent. WHAT IS KNOWN ALREADY: The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis. STUDY DESIGN, SIZE, DURATION: A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology. PARTICIPANTS/MATERIALS, SETTING, METHODS: All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants. MAIN RESULTS AND THE ROLE OF CHANCE: There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32–82%) and 95% (95% CI 90–98%), respectively, and for all MRI techniques were 81% (95% CI 66–90%) and 83% (95% CI 62–94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30–80%) and 100% (95% CI 92–100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29–74%) and 98% (95% CI 95–99%), respectively, and for all MRI techniques were 64% (95% CI 40–83%) and 98% (96% CI 93–99%). Pooled analyses were not possible for other imaging modalities. LIMITATIONS, REASONS FOR CAUTION: There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease. WIDER IMPLICATIONS OF THE FINDINGS: MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women’s and Children’s Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics. REGISTRATION NUMBER: Prospective registration with PROSPERO (CRD42017059872) was obtained.

Background: Enhanced recovery after surgery (ERAS) is a multimodal protocol which aims to facilitate faster discharge from hospital and recovery after surgery by minimising physiological and physical stress on the body before, during and after surgery.Aims: The aim of this study is to evaluate patient satisfaction while being managed with the ERAS pathway and to determine whether it is an acceptable model of care in this respect.Materials and Methods: The study is an observational study of patient satisfaction in ERAS in gynaecological oncology. Patients who underwent laparoscopy or laparotomy for malignancy or suspected malignancy were asked to complete a validated questionnaire (EORTC IN‐PATSAT32) prior to discharge from hospital after surgery.Results: There were 113 (75.33%) patients recruited out of 150 patients who were approached. There were 68 cases of laparotomy and 45 cases of laparoscopy. There were no statistically significant differences between baseline characteristics of responders and non‐responders in both the laparotomy and the laparoscopy group. Patients reported high levels of satisfaction, with a mean score for general satisfaction of 92.2 (SD 11.44 ± 1.387) in the laparotomy group and 92.4 (SD 10.69 ± 1.594) for the laparoscopy group.Conclusions: The results of our study reflect high levels of patient satisfaction in both the laparotomy and laparoscopy groups. This could be attributed to a strong focus on discharge planning through a multi‐disciplinary approach, specifically addressing key aspects to recovery from initial consultation. The study reflects the successful implementation of an ERAS protocol with gynaecological oncological surgery in this unit.

Objectives: To review the accuracy of different imaging modalities for the detection of rectosigmoid deep endometriosis (DE) in women with clinical suspicion of endometriosis, and to determine the optimal modality.Methods: A search was conducted using PubMed, MEDLINE, Scopus, EMBASE and Google Scholar to identify studies using imaging to evaluate women with suspected DE, published from inception to May 2020. Studies were considered eligible if they were prospective and used any imaging modality to assess preoperatively for the presence of DE in the rectum/rectosigmoid, which was then correlated with the surgical diagnosis as the reference standard. Eligibility was restricted to studies including at least 10 affected and 10 unaffected women. The QUADAS‐2 tool was used to assess the quality of the included studies. Mixed‐effects diagnostic meta‐analysis was used to determine the overall pooled sensitivity and specificity of each imaging modality for rectal/rectosigmoid DE, which were used to calculate the likelihood ratio of a positive (LR+) and negative (LR–) test and diagnostic odds ratio (DOR).Results: Of the 1979 records identified, 30 studies (3374 women) were included in the analysis. The overall pooled sensitivity and specificity, LR+, LR– and DOR for the detection of rectal/rectosigmoid DE using transvaginal sonography (TVS) were, respectively, 89% (95% CI, 83–92%), 97% (95% CI, 95–98%), 30.8 (95% CI, 17.6–54.1), 0.12 (95% CI, 0.08–0.17) and 264 (95% CI, 113–614). For magnetic resonance imaging (MRI), the respective values were 86% (95% CI, 79–91%), 96% (95% CI, 94–97%), 21.0 (95% CI, 13.4–33.1), 0.15 (95% CI, 0.09–0.23) and 144 (95% CI, 70–297). For computed tomography, the respective values were 93% (95% CI, 84–97%), 95% (95% CI, 81–99%), 20.3 (95% CI, 4.3–94.9), 0.07 (95% CI, 0.03–0.19) and 280 (95% CI, 28–2826). For rectal endoscopic sonography (RES), the respective values were 92% (95% CI, 87–95%), 98% (95% CI, 96–99%), 37.1 (95% CI, 21.1–65.4), 0.08 (95% CI, 0.05–0.14) and 455 (95% CI, 196–1054). There was significant heterogeneity and the studies were considered methodologically poor according to the QUADAS‐2 tool.Conclusions: The sensitivity of TVS for the detection of rectal/rectosigmoid DE seems to be slightly better than that of MRI, although RES was superior to both. The specificity of both TVS and MRI was excellent. As TVS is simpler, faster and more readily available than the other methods, we believe that it should be the first‐line diagnostic tool for women with suspected DE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Objective: In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two‐ (2D) and three‐ (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).Methods: This was a prospective observational study performed between October 2008 and November 2011 in a tertiary referral laparoscopic unit. All women scheduled to undergo LH were included and underwent detailed preoperative transvaginal US. Uterine volumes were calculated using 2D‐US measurements (ellipsoid formula), and using Virtual Organ Computer‐aided AnaLysis (VOCAL™) having acquired 3D‐US volumes of the uterus. Age, parity, need to morcellate and final uterine dry weight at histology were recorded. The estimated uterine volumes were then incorporated into a previously published logistic regression model to predict the need to morcellate for both nulliparous and parous women. The probability threshold cut‐off of 0.14 (95% sensitivity) was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios (LRs). The performance of the models incorporating 2D‐ and 3D‐US calculations were compared with 2D‐ and 3D‐US‐generated volumes alone, using receiver–operating characteristics (ROC) curves.Results: Of 76 women who underwent LH during the study period, 79% (n = 60) had complete background and 3D‐US data. Their mean age was 43.7 years, 91.7% were parous and 35% underwent morcellation. The greatest uterine volume that did not require morcellation was 404 mL estimated using 3D‐US, which corresponded to a uterine volume of 688.8 mL using 2D‐US. The smallest uterine volume that required morcellation was 118.9 mL using 3D‐US, which corresponded to a uterine volume of 123.4 mL using 2D‐US. The 3D‐US uterine volume for parous women with a sensitivity of 95% based on ROC‐curve analysis was approximately 120 mL, which equated to a predicted probability of morcellation cut‐off of 0.14. For this cut‐off, specificity was 55.00%, PPV was 51.35%, NPV was 95.65%, LR+ was 2.11 and LR– was 0.09. Areas under the ROC curves for the morcellation logistic regression model were 0.769 (95% CI, 0.653–0.886) and 0.586 (95% CI, 0.419–0.753) using uterine volumes obtained by 3D‐US and by 2D‐US, respectively, and they were 0.938 (95% CI, 0.879–0.996) and 0.815 (95% CI, 0.681–0.948) using 3D‐US and 2D‐US volumes alone.Conclusions: The need to morcellate can be predicted preoperatively using 3D‐US uterine volumes obtained by transvaginal US with a fair degree of accuracy. Uteri with volumes smaller than 120 mL at 3D‐US are very unlikely to require morcellation. The incorporation of 3D‐US‐estimated uterine volume into the previously published logistic regression model does not seem to confer any significant improvement when compared with 3D‐US uterine volume alone to predict the need to morcellate in women undergoing total LH. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.