Daria Schettini

Purpose: Dynamic magnetic resonance defecography (MRD) is a key imaging modality for comprehensive evaluation of pelvic floor dysfunction, enabling detailed multiplanar anatomical and functional assessment without ionizing radiation. However, despite its established clinical role, MRD reporting is heterogeneous among centers, hindering standardized interpretation, multidisciplinary communication, and comparison across studies. This modified Delphi consensus study aimed to develop a standardized referral dataset and structured reporting framework for MRD. Methods: A multidisciplinary panel of 20 Italian experts (radiologists, colorectal surgeons, gynecologists, urologists, gastroenterologists, physiatrists, and a methodologist) conducted a three-round Delphi process to develop consensus-based templates for MRD referral and reporting. Consensus was set at ≥75% agreement. A total of 36 items were evaluated, covering technical parameters, anatomical/functional findings, and reporting format. Results: Consensus was achieved for 21 items (58%), including technical parameters, standardized measurements (anorectal angle, pubococcygeal line), and clinically relevant descriptors (prolapse, dyssynergia, rectocele, rectal inertia). A structured referral template was also developed to improve information transfer from clinicians to radiologists. Both tools were unanimously endorsed. Conclusions: This modified Delphi consensus study provides a multidisciplinary framework for standardized MRD referral and reporting. The proposed reporting template may facilitate greater consistency in image interpretation, reporting terminology, and multidisciplinary communication. These recommendations may serve as a foundation for the harmonization of MRD practice and future validation studies in pelvic floor imaging.

Purpose: This study was conducted to evaluate the validity of a new imaging-guided, anatomy-based classification of anorectal fistulas in defining disease severity and predicting surgical outcomes.Methods: This multicenter, retrospective cohort study analyzed data from patients with perianal fistulas who underwent surgery between 2017 and 2023. All patients underwent preoperative 3-dimensional endoanal ultrasound, with adjunctive magnetic resonance imaging performed if ultrasound indicated a complex fistula. Imaging examinations were retrospectively evaluated to categorize fistulas according to the Garg classification and the newly proposed classification system. The new classification included 6 severity grades based on the characteristics of the primary tract: submucosal, intersphincteric, low transsphincteric, high transsphincteric, multiple, and suprasphincteric/extrasphincteric. Each grade was further subdivided into 3 subtypes (A, B, C) based on the extension of secondary tracts.Results: When compared with the new classification, the Garg classification demonstrated a slightly lower ability to predict the feasibility of fistulotomy in simple fistulas (94.2% vs 99.1%; Fisher exact test, P=0.006). A strong positive correlation was found between the surgery failure rate and the severity grade of the new classification (Spearman rho, 0.90; P<0.001), whereas the Garg classification showed a nonsignificant positive correlation with surgical failure rate (Spearman rho, 0.90; P=0.08).Conclusion: The new imaging-guided, anatomy-based classification of anorectal fistulas demonstrates high accuracy in defining disease severity. It represents a valuable tool for preoperative grading of anal fistulas, standardizing the reporting of diagnostic imaging, and improving the communication of findings among healthcare professionals.