Ultrasound Based Staging System As A Triage Tool For
Laparoscopic Treatment Of Endometriosis
Menakaya U, Reid S, Lu C, Condous G
Fellow and Clinical Associate LecturerAcute Gynaecology, Early Pregnancy and Advanced Endoscopic Unit
Nepean Hospital and University of Sydney Medical SchoolKingswood, Penrith
Background• WES recommendation - Centers of expertise for
management of higher stage endometriosis.
• Recommendation requires a triaging system
• Current triaging systems are intraoperative
• Associated with high health costs and surgical risks for patients
Objectives
• To develop a practical pre-operative ultrasound based staging system to predict severity of endometriosis
1. Correlate ultrasound prediction of components of staging system with gold standard laparoscopy
2. Utilize staging system to triage women to appropriate surgical expertise.
Materials & Methods
• Multicentre prospective observational study
• January 2009 to February 2013
• Setting: endometriosis referral centre, university hospital, private
sites
• Patients: 200 women, reproductive age, history of chronic pelvic
pain or endometriosis
• Women included had complete ultrasound and laparoscopy data
•Ultrasound data– Same systematic approach inclusive of all phenotypes of endometriosis
(peritoneal disease, adhesions, DIE, endometriomata)– Same advanced gynaecology sonologists
•Pre-operative ultrasound staging system (I – IV) – developed retrospectively– Grouped together specific pelvic features on TVS– Associated with endometriosis
•Assignment of AGES laparoscopic skill level (I – VI)– Operative findings recorded in database– Different laparoscopic surgeons involved– Skill levels assigned.
Materials & Methods
Domain TVS Technique
Endometriosis Phenotype
1 Routine assessment of uterus and adnexa
• Uterine version• Adenomyosis
• Ovarian endometriosis
Domain Based TVS Approach To EvaluationOf Pelvis In Endometriosis
Domain TVS Technique
Endometriosis Phenotype
2 Soft markers for endometriosis
• Possible peritoneal disease
• Ovarian adhesions
Domain TVS Technique
Endometriosis Phenotype
3 Real time dynamic “sliding sign”
POD obliteration
Domain TVS Technique
Endometriosis Phenotype
4 Office Gel Sonovaginography
Non bowel Posterior compartment DIE
5 Assessment of anterior wall of large bowel
Bowel DIE
“The Endometriosis Scan”
EndometriomaBowel and Non bowel DIE
Peritoneal disease
Endometriosis Phenotypes
AdhesionsAdhesions
ULTRASOUND MARKER ACCURACY % SENSITIVITY %
Endometrioma
Left
Right
Bilateral
80.4
82.4
86
77.1
66
63.2
Deep Infiltrating Endometriosis (total) 87.9 78.5
Midline posterior compartment 89 83.3
Lateral posterior compartment 91.5 23.5
POD obliteration 96 90.2
Performance Of Specific TVS Markers Vs. gold standard laparoscopy
RESULTS
STAGES
Stage 1
Stage 2
Stage 3
Stage 4
FEATURES ASSESSED ON TRANSVAGINAL ULTRASOUND
Soft marker –site specific tenderness in POD with mobile ovaries
Endometrioma - absentPOD – Positive sliding sign
DIE nodules – Absent
Soft marker – site specific tenderness in POD with/without mobile ovaries
Endometrioma - PresentPOD – Positive sliding sign
DIE nodules – Absent
Soft marker – site specific tenderness in POD with/without mobile ovaries
Endometrioma – present or absentPOD – Positive sliding sign
DIE nodules – Present
Soft marker – site specific tenderness in POD with/without Mobile ovaries
Endometrioma – present or absentPOD – Negative sliding sign
DIE nodules – Present
PREDICTED FINDINGS AT LAPAROSCOPY
Possible peritoneal disease alone
Ovarian endometriosis +/- Peritoneal disease
Normal PODDIE nodules absent
Peritoneal disease +/- ovarian endometriosis Normal POD
DIE nodules present
Peritoneal disease +/- ovarian endometriosis
Obliterated PODDIE nodules present
AGES LAPAROSCOPIC
SKILL LEVEL
Level 1 - 2
Level 3
Level 4
Ultrasound stage I – IV, Predicted laparoscopic findings and
AGES skill level I - VI
Level 6
TVS Stage Surgical Skill Level
Level 1-2 Level 3 Level 4 Level 6
Stage 1 81 3 3 1
Stage 2 16 21 3 1
Stage 3 4 0 7 4
Stage 4 1 2 0 46
• 80.3% accurate prediction of exact laparoscopic skills required.
Correlating ultrasound stages (I-IV) and AGE laparoscopic skill levels (I – VI)
DISCUSSION
• Practical, simple and comprehensive preoperative staging system for endometriosis.
• Key differences with other staging system.– Preoperative– Woman centred– Inclusive of all phenotypes – Spectrum of hard markers
• Criticisms– Retrospective staging – Stage 3: DIE locations require different lap skill sets – Poor performance - Stage 2 and 3 – learning curve
required.
CONCLUSION
• Potential role in preoperative triage of patients with higher stage disease.
• For General practitioners - Engender appropriate referral
• For Generalists - Appreciation of severity of disease
• For AGES advanced - Preoperative counseling laparoscopists Surgical list planning,
Multidisciplinary team involvement (colorectal, urology etc. )
• Large-scale multi center prospective studies are needed to validate this staging system
Thank you
PHENOTYPES OF ENDOMETRIOSIS
Peritoneal endometriosis
Ovarian adhesions
Posterior compartment adhesions(POD obliteration)
DIE nodules(Bowel and non bowel)
Ovarian endometrioma
Endometriosis phenotypes, ultrasound findings and gold standard laparoscopy
