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Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification
Abstract
Objective:
To use the ENZIAN classification for preoperative estimation of laparoscopic operating time in patients with deeply infiltrating endometriosis (DIE).
Study design:
Retrospective study of women with DIE (n=151) who underwent laparoscopic surgery.
Results:
151 of 470 patients had DIE (n=205 lesions) exclusively in compartments A (rectovaginal septum, vagina), B (sacrouterine ligament to the pelvic wall) and C (rectum, sigmoid colon). These laparoscopically treated lesions were used to calculate a model for estimating operating time for DIE, assuming complication-free procedures (overall significance for model's predictive power: P<0.001). The error of estimation for the operating time prediction is 0 ± 35.35 min (mean ± SD; range -83 to +117 min). The actual operating time for all operations was 109.32 ± 74.38 min (mean ± standard deviation).
Conclusions:
Using a model for predicting operating time based on the ENZIAN classification enables resources to be planned more precisely in surgery management. Patients with DIE can also be given more precise information regarding the expected operating time.
... We present the following article in accordance with the Narrative Review reporting checklist (available at https:// dx.doi.org/10.21037/gpm- [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]. ...
... The Enzian scoring system was validated by demonstrating a correlation between the localization of DE and the symptoms (26). Haas et al. demonstrated that the Enzian classification correlates with the duration and the difficulty of surgery (29) and that some postoperative complications correlate with specific locations. ...
... The detailed description of the disease enables better care of the patient concerning symptoms, clinical findings, and therapy as well as scientific studies. [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]. The series "Endometriosis Surgery" was commissioned by the editorial office without any funding or sponsorship. ...
Objective: Progress in the diagnosis and treatment of endometriosis, especially deep endometriosis (DE) needs one classification system with all types of the disease i.e., peritoneal, ovarian and DE and the associated adhesions.
Background: To describe the various forms of the disease, preoperative diagnostic imaging by transvaginal sonography (TVS) and by magnetic resonance imaging (MRI) have developed their classification systems, which unfortunately are different from surgical classification systems.
Methods: The #Enzian classification for endometriosis is systematically presented and discussed in detail and by means of an example. Based on a narrative literature review, and simultaneous analysis of the results available so far in relation to the Enzian classification, the need for further development of this classification is critically evaluated. The most widely used revised American Society for Reproductive Medicine (rASRM) classification does not reflect DE. It moreover is complex to use and poorly reproducible. The Enzian classification, developed to describe surgery for DE, has now been used for 15 years and was demonstrated to accurately and reliably describe DE. However, peritoneal and ovarian lesions and a description of tubo- ovarian adhesions were missing. Given the need for one complete classification system, meeting the requirements of the surgeon, the sonographer, and the radiologist, and permitting to explain endometriosis comprehensively to the patient, a new #Enzian classification was developed. It describes, the anatomical location, the size of the lesions, and the involvement of the genital tract and adjacent organs.
Conclusions: The new #Enzian classification permits the classification of superficial, ovarian, deep, and extragenital endometriosis and pelvic adhesions. It is a unified and comprehensive description of the type and severity of endometriosis serving preoperative imaging (ultrasound, MRI) and surgery, thus facilitating clinical research.
Keywords: Endometriosis; classification; #Enzian classification; ultrasound; surgery
... Several studies reported that MRI evaluation is highly accurate for preoperative surgical planning [10], in accordance with the European Society of Urogenital Radiology's (ESUR) guidelines 2017 [6]; in fact many large centers utilize these studies routinely, especially in the case of equivocal recto-vaginal, ureteral, or bladder endometriosis [18][19][20]. It follows that MRI is assuming an increasingly central role in the pre-operative diagnosis of endometriotic disease [21][22][23][24][25]. ...
... Comparing rASRM and previous ENZIAN score (2011), Montanari et al. highlighted these limitations by assessing a significant association between DIE extent and symptoms when described by the ENZIAN classification (2011) [27]. Furthermore, the ENZIAN score 2011 showed a good correlation between preoperative MRI features and intraoperative findings in patients with DIE [24,28]. Recent literature has also evaluated interreader agreement with this classification, showing varying results; Thomassin-Naggara et al.'s trial (2020) consisted of 150 cases affected by DIE. ...
Structured reporting systems for endometriotic disease are gaining a central role in diagnostic imaging: our aim is to evaluate applicability and the feasibility of the recent ENZIAN score (2020) assessed by MRI. A total of 60 patients with suspected tubo–ovarian/deep endometriosis were retrospectively included in our study according to the following criteria: availability of MR examination; histopathological results from laparoscopic or surgical treatment; patients were not assuming estro-progestin or progestin therapy. Three different readers (radiologists with 2-, 5-, and 20-years of experience in pelvic imaging) have separately assigned a score according to the ENZIAN score (revised 2020) for all lesions detected by magnetic resonance imaging (MRI). Our study showed a high interobserver agreement and feasibility of the recent ENZIAN score applied to MRI; on the other hand, our experience highlighted some limitations mainly due to MRI’s inability to assess tubal patency and mobility, as required by the recent score (2020). In view of the limitations which arose from our study, we propose a modified MRI-ENZIAN score that provides a complete structured reporting system, more suitable for MRI. The high interobserver agreement of the recent ENZIAN score applied to MRI confirms its validity as a complete staging system for endometriosis, offering a shared language between radiologists and surgeons.
... In detail, exception rules for the rASRM consisted of assignment of 16 points to the fallopian tube with a complete enclosure of the fimbria by adhesions and multiplied points on the remaining tube and ovary due to the missing adnexa (1997). For the Enzian classification bilateral involvement needs to be assigned with two characters (Haas et al., 2013b). Furthermore, negative findings in compartment A, B and C need to be described as well (Haas et al., 2013a,b). ...
... Enzian 1. Bilateral involvement noted with two letter for B (BB) and FU (FUU) (Haas et al., 2013b) 2. Negative findings for compartment ABC are noted, A0B0C0 (Haas et al., 2013a,b) EFI 1. If an ovary is absent on one side, the LF score is obtained by doubling the lowest score on the side with the ovary (Adamson and Pasta, 2010). ...
STUDY QUESTION
Is electronic digital classification/staging of endometriosis by the EQUSUM application more accurate in calculating the scores/stages and is it easier to use compared to non-digital classification?
SUMMARY ANSWER
We developed the first digital visual classification system in endometriosis (EQUSUM). This merges the three currently most frequently used separate endometriosis classification/scoring systems (i.e. revised American Society for Reproductive Medicine (rASRM), Enzian and Endometriosis Fertility Index (EFI)) to allow uniform and adequate classification and registration, which is easy to use. The EQUSUM showed significant improvement in correctly classifying/scoring endometriosis and is more user-friendly compared to non-digital classification.
WHAT IS KNOWN ALREADY
Endometriosis classification is complex and until better classification systems are developed and validated, ideally all women with endometriosis undergoing surgery should have a correct rASRM score and stage, while women with deep endometriosis (DE) should have an Enzian classification and if there is a fertility wish, the EFI score should be calculated.
STUDY DESIGN, SIZE, DURATION
A prospective endometriosis classification proof of concept study under experts in deep endometriosis was conducted. A comparison was made between currently used non-digital classification formats for endometriosis versus a newly developed digital classification application (EQUSUM).
PARTICIPANTS/MATERIALS, SETTING, METHODS
A hypothetical operative endometriosis case was created and summarized in both non-digital and digital form. During European endometriosis expert meetings, 45 DE experts were randomly assigned to the classic group versus the digital group to provide a proper classification of this DE case. Each expert was asked to provide the rASRM score and stage, Enzian and EFI score. Twenty classic forms and 20 digital forms were analysed. Questions about the user-friendliness (system usability scale (SUS) and subjective mental effort questionnaire (SMEQ)) of both systems were collected.
MAIN RESULTS AND THE ROLE OF CHANCE
The rASRM stage was scored completely correctly by 10% of the experts in the classic group compared to 75% in the EQUSUM group (P < 0. 01). The rASRM numerical score was calculated correctly by none of the experts in the classic group compared with 70% in the EQUSUM group (P < 0.01). The Enzian score was correct in 60% of the classic group compared to 90% in the EQUSUM group (P = 0.03). EFI scores were calculated correctly in 25% of the classic group versus 85% in the EQUSUM group (P < 0.01). Finally, the usability measured with the SUS was significantly better in the EQUSUM group compared to the classic group: 80.8 ± 11.4 and 61.3 ± 20.5 (P < 0.01). Also the mental effort measured with the SMEQ was significant lower in the EQUSUM group compared to the classic group: 52.1 ± 18.7 and 71.0 ± 29.1 (P = 0.04). Future research should further develop and confirm these initial findings by conducting similar studies with larger study groups, to limit the possible role of chance.
LIMITATIONS, REASONS FOR CAUTION
These first results are promising, however it is important to note that this is a preliminary result of experts in DE and needs further testing in daily practice with different types (complex and easy) of endometriosis cases and less experienced gynaecologists in endometriosis surgery.
WIDER IMPLICATIONS OF THE FINDINGS
This is the first time that the rASRM, Enzian and EFI are combined in one web-based application to simplify correct and automatic endometriosis classification/scoring and surgical registration through infographics. Collection of standardized data with the EQUSUM could improve endometriosis reporting and increase the uniformity of scientific output. However, this requires a broad implementation.
STUDY FUNDING/COMPETING INTEREST(S)
To launch the EQUSUM application, a one-time financial support was provided by Medtronic to cover the implementation cost. No competing interests were declared.
TRIAL REGISTRATION NUMBER
N/A.
... Recent research evaluating MRI as a diagnostic instrument in endometriosis, particularly in DIE, has shown convincing results [9,[16][17][18][19][20]. The diagnostic and therapeutic procedures are surely demanding in view of the complex character of endometriosis and the lack of correlation between objective findings and the patient's symptoms. ...
... Lesions in compartment B showed the lowest accordance among the main compartments A-C (Sens. 78.4%, NPV 56.0%) and were distinctly lower compared to other studies [19,21]. In one case, a big C3 lesion may have superseded a B3 lesion (MRI-classified B1) and aggravated the detection. ...
Purpose
Comparison of preoperative magnetic resonance imaging (MRI) with intraoperative findings in patients with deep infiltrating endometriosis (DIE) by means of the ENZIAN score.
Methods
This retrospective two-center study includes 63 patients with deep infiltrating endometriosis, who underwent surgery between 2012 and 2016 at both the University Hospital of Zurich and the Cantonal Hospital of Schaffhausen. Inclusion criteria were a preoperative pelvic MRI and intraoperative or bioptic confirmation of DIE. The preoperative MRI findings were compared with the intraoperative results by means of the ENZIAN score. Furthermore, the various MRI sequences were analyzed for their diagnostic value based on a Likert scale.
Results
Sensitivity and negative predictive values of MRI confirmed by surgery were 95.2% and 91.7% (lesions in the vaginal/rectovaginal space), 78.4% and 56% (uterosacral ligaments), 91.4% and 89.7% (rectum/sigmoid colon), 57.1% and 94.1% (myometrium), 85.7% and 98.3% (bladder), and 73.3% and 92.2% (intestine), respectively. T2 axial and sagittal MRI sequences in combination with a T1 sequence were diagnostically sufficient.
Conclusions
The MRI-based ENZIAN score correlates well with the intraoperative findings, enabling a better planning of the surgical procedure for patients and physicians. However, considerable difficulty and a poorer comparability result from the variations in sequences used in the detection of this multifaceted disease. Therefore, a standardization of MRI protocols used in the detection of DIE will be a crucial step towards increased diagnostic validity and the ENZIAN score may be used as an anatomical land map and valuable communication tool between radiologists and gynecologists.
... Among the current staging system, the revised ENZIAN score of 2010 ( Fig. 1) has been demonstrated an excellent score for morphological description of deep endometriosis [14,18]. ...
... Moreover ENZIAN score can also suggest the best surgical strategy for colo-rectal endometriosis: in our series 5/7 (71.4%) patients with 1C lesions underwent to the excision of lesions, while 5/7 (71.4%) patients with 2C lesions and 8/8 (100%) patients with 3C lesions need the segmental resection of rectum-sigmoid colon. So ENZIAN score may be able also to predict complexity and the type of surgical approach, with particular regard to bowel resection [18]. ...
Purpose
To determine the accuracy of ENZIAN score, as detected on MR imaging, compared to surgical-pathologic findings.
Materials and methods
This retrospective study was approved by the investigational review board and the requirement for informed patient consent was waived. 115 patients were included according to following criteria: tubo-ovarian and/or deep endometriosis suspected at physical examination and transvaginal ultrasound; availability of MR examination; histopathological results from laparoscopic or surgical treatment. Exclusion criteria: lack of available MR examination, and/or (b) lack of a definitive histopathological results.
Histopathological findings from bioptic specimens obtained during laparoscopic or laparotomic treatment were considered as reference standard.
For all detected lesions a score according to ENZIAN score (revised 2010) was assigned both for MRI and histopathological findings.
By comparing MRI-ENZIAN score and histopathological-ENZIAN score the overall sensitivity, specificity, accuracy, positive and negative predictive values in relation to presence/absence of deep endometriosis in each patient were calculated. k-Cohen to evaluate the degree of concordance between MRI-ENZIAN score and histopathological-ENZIAN score was also measured. Moreover the sensitivity, specificity, accuracy, positive and negative predictive values for each specific localization provided by ENZIAN score were also calculated.
Results
At histopathology, the diagnosis of deep endometriosis was confirmed in 82/115 (71.3%) patients.
The sensitivity, specificity, accuracy, PPV and NPV of MRI were 94%, 97%, 95%, 99%, 86%, respectively. The highest accuracy was for adenomyosis (100%) and endometriosis of utero-sacral ligaments (USLs) (98%), slightly lower for vagina-rectovaginal septum an colo-rectal walls (96%), and the lowest for bladder endometriosis (92%).
The concordance between histopathological and MRI ENZIAN score was excellent (k = 0.824); in particular it was 0.812 for lesions in vagina-rectovaginal space, 0.890 for lesions in USL, 0.822 for lesions in rectum–sigmoid colon, 1.000 for uterine adenomyosis, and 0.367 for lesions located in the bladder wall.
Conclusion
MRI correlates with the ENZIAN score and has an accuracy of 95% in the detection and localization of deep endometriosis, allowing to minimize false negative results (4%) in patients with deep endometriosis and to obtain a correct preoperative staging.
... Similarly, ureteral and parametrial involvement or the combination of different pelvic DE lesions influences both symptoms and the expected complexity of surgical treatment. Proper preinvasive recognition of disease extent and #Enzian classification using sonography or MRI can help to ensure an accurate assessment of both the indication and the anticipated surgical procedure [57,64]. Both improve patient counseling and the planning of interdisciplinary procedures, if necessary. ...
Gynecological ultrasonography plays a central role in the management of endometriosis. The rapid technical development as well as the currently increasing evidence for non-invasive diagnostic methods require an updated compilation of recommendations for the use of ultrasound in the management of endometriosis. The present work aims to highlight the accuracy of sonography for diagnosing and classifying endometriosis and will formulate the present list of key messages and recommendations. This paper aims to demonstrate the accuracy of TVS in the diagnosis and classification of endometriosis and to discuss the clinical applications and consequences of TVS findings for indication, surgical planning and assessment of associated risk factors. (1) Sophisticated ultrasound is the primary imaging modality recommended for suspected endometriosis. The examination procedure should be performed according to the IDEA Consensus. (2) Surgical intervention to confirm the diagnosis alone is not recommended. A preoperative imaging procedure with TVS and/or MRI is strongly recommended. (3) Ultrasound examination does not allow the definitive exclusion of endometriosis. (4) The examination is primarily transvaginal and should always be combined with a speculum and a bimanual examination. (5) Additional transabdominal ultrasonography may enhance the accuracy of the examination in case of extra pelvic disease, extensive findings or limited transvaginal access. (6) Sonographic assessment of both kidneys is mandatory when deep endometriosis (DE) and endometrioma are suspected. (7) Endometriomas are well defined by sonographic criteria. When evaluating the ovaries, the use of IOTA criteria is recommended. (8) The description of sonographic findings of deep endometriosis should be systematically recorded and performed using IDEA terminology. (9) Adenomyosis uteri has sonographically well-defined criteria (MUSA) that allow for detection with high sensitivity and specificity. MRI is not superior to differentiated skilled ultrasonography. (10) Classification of the extent of findings should be done according to the #Enzian classification. The current data situation proves the best possible prediction of the intraoperative situs of endometriosis (exclusive peritoneum) for the non-invasive application of the #Enzian classification. (11) Transvaginal sonographic examination by an experienced examiner is not inferior to MRI diagnostics regarding sensitivity and specificity in the prediction of the extent of deep endometriosis. (12) The major advantage of non-invasive imaging and classification of endometriosis is the differentiated planning or possible avoidance of surgical interventions. The recommendations represent the opinion of experts in the field of non-invasive and invasive diagnostics as well as therapy of endometriosis. They were developed with the participation of the following national and international societies: DEGUM, ÖGUM, SGUM, SEF, AGEM/DGGG, and EEL.
... The AAGL score discriminated between four stages of surgical complexity with high reproducibility, whereas the rASRM score discriminated between the complexity stages with poor reproducibility . In this regard, previous studies have also shown a reliable estimation of surgical complexity when using the Enzian classification for intraoperative classification of DE (Haas et al., 2013;Roman et al., 2016;Poupon et al., 2019). The results of the present work demonstrate that the rASRM score underrates the extent of endometriosis. ...
STUDY QUESTION
How is endometriosis extent described by the #Enzian classification compared to the revised American Society for Reproductive Medicine (rASRM) stages in women undergoing radical surgery for deep endometriosis (DE)?
SUMMARY ANSWER
The prevalence and severity grade of endometriotic lesions and adhesions as well as the total number of #Enzian compartments affected by DE increase on average with increasing rASRM stage; however, DE lesions are also present in rASRM stages 1 and 2, leading to an underestimation of disease severity when using the rASRM classification.
WHAT IS KNOWN ALREADY
Endometriotic lesions can be accurately described regarding their localization and severity by sonography as well as during surgery using the recently updated #Enzian classification for endometriosis.
STUDY DESIGN, SIZE, DURATION
This was a prospective multicenter study including a total of 735 women between January 2020 and May 2021.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Disease extent in women undergoing radical surgery for DE at tertiary referral centers for endometriosis was intraoperatively described using the #Enzian and the rASRM classification.
MAIN RESULTS AND THE ROLE OF CHANCE
A total of 735 women were included in the study. Out of 31 women with rASRM stage 1, which is defined as only minimal disease, 65% (i.e. 20 women) exhibited DE in #Enzian compartment B (uterosacral ligaments/parametria), 45% (14 women) exhibited DE in #Enzian compartment A (vagina/rectovaginal septum) and 26% (8 women) exhibited DE in #Enzian compartment C (rectum). On average, there was a progressive increase from rASRM stages 1–4 in the prevalence and severity grade of DE lesions (i.e. lesions in #Enzian compartments A, B, C, FB (urinary bladder), FU (ureters), FI (other intestinal locations), FO (other extragenital locations)), as well as of endometriotic lesions and adhesions in #Enzian compartments P (peritoneum), O (ovaries) and T (tubo-ovarian unit). In addition, the total number of #Enzian compartments affected by DE lesions on average progressively increased from rASRM stages 1–4, with a maximum of six affected compartments in rASRM stage 4 patients.
LIMITATIONS, REASONS FOR CAUTION
Interobserver variability may represent a possible limitation of this study.
WIDER IMPLICATIONS OF THE FINDINGS
The #Enzian classification includes the evaluation of DE in addition to the assessment of endometriotic lesions and adhesions of the ovaries and tubes and may therefore provide a comprehensive description of disease localization and extent in women with DE.
STUDY FUNDING/COMPETING INTEREST(s)
No funding was received for this study. All authors declare that they have no conflict of interest.
TRIAL REGISTRATION NUMBER
N/A.
... The Enzian score and the adenomyosis classification were established on the basis of a radiologist's review of the patient's pelvic MRI scans. The Enzian score was created in 2005 by a German team and revised in 2011 to describe deep pelvic endometriosis lesions in the retroperitoneal space [8]. This last one was used in this study. ...
Introduction
Endometriosis is a chronic inflammatory disease with a negative impact on fertility. The Enzian classification provides a precise description of deep pelvic endometriotic lesions, especially in the retroperitoneal area, from preoperative pelvic MRI scans. However, it is not known if it is correlated with postoperative fertility.
Study objective
To determine if there is an association between the preoperative Enzian score and postoperative fertility after deep pelvic endometriosis surgery.
Design
We conducted a descriptive, retrospective study using information from the ENDOREN database.
Setting
This was a retrospective study at the Department of Obstetrics and Gynecology at Rennes University Hospital (France) from January 2013 to May 2019
Patients and interventions
We used information from the ENDOREN database that included all women who underwent surgery for deep endometriosis and wish to conceive. This surgery was intended in a view to achieve a complete removal of endometriosis.
Measurements
The Enzian score was calculated from preoperative MRI scans, and total, spontaneous, and after In Vitro Fertilization (IVF) live births and pregnancies outcomes were collected from the patients'computerized medical records. Univariate and multivariate analysis was performed.
Results
Sixty-eight patients were included. The live-birth rate was 35% (24/68). According to the Enzian classification, 25 patients (35%) were classified in compartment A, 64 patients (94%) in compartment B, and 27 (40%) in compartment C. In multivariate analysis, positive predictor of live birth was single Enzian B score (OR=4.7[1.21; 18.81], p=0.03), negative predictors were uterine adenomyosis and a history of endometriosis surgery. In multivariate analysis, positive predictor of spontaneous live birth was EFI score ≥7 (OR =22.434; CI [1.138; 442.190]). In multivariate analysis, positive predictor was Enzian A score (OR=15.9[2.2; 114.7], p=0.006), and negative predictors was uterine adenomyosis and Enzian B score (OR=0.01[0; 0.495], p=0.02) for live birth after IVF.
Conclusion
The present retrospective study cannot strongly conclude about fertility and correlation with Enzian score because the groups are too small. However, it seems that when solely the compartment B is involved by endometriosis, complete full removal of endometriosis leads to better post-operative live births results. Other studies must be done to determine if Enzian classification based on preoperative pelvic MRI could be clinical value in the decision-making strategy for managing infertile patients with deep pelvic endometriosis.
... A correlation between ENZIAN and DIE symptoms was demonstrated in terms of location and severity [24,25]. Moreover, ENZIAN demonstrated a correlation between DIE symptoms, the extent of the disease, and surgery length [25][26][27]. However, regardless of the intraoperative classification, TVUS and MRI remain the most valuable preoperative diagnostic tools. ...
Purpose
The aim of this study is to investigate the correlation between the magnetic resonance imaging (MRI) and intraoperative findings of deep infiltrating endometriosis using the #ENZIAN score.
Methods
This retrospective study included 64 patients who underwent surgery for deep infiltrating endometriosis between January 2017 and August 2020. Preoperative abdominopelvic MRI assessment was evaluated and scored using the #ENZIAN classification. Operative scores were considered the gold standard, and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of MRI for each category were calculated.
Results
MRI has higher sensitivity and specificity in showing the lesions of the compartments O (ovarian lesions), A (rectovaginal septum and posterior vaginal fornix), and B (uterosacral ligaments and parametrium) (100–100%, 100–100%, and 97–100%, respectively, p < 0.001) compared to the other compartments. The lowest sensitivity, specificity, accuracy, and PPV of the MRI was found in compartment P (14%, 76%, 70%, and 7%, respectively).
Conclusion
We demonstrated that the #ENZIAN classification in MRI reports has significant sensitivity and specificity in compartments A, B (uterosacral ligaments and parametrium), and O. Furthermore, the determination of peritoneal lesions via MRI is inadequate.
... The use of the ENZIAN classification system was further extrapolated for its use in pre-operative assessment with imaging. Two studies evaluated this MRIbased ENZIAN system (Burla et al., 2019, Di Paola et al., 2015, and a third study reported on a model to predict operation time based on the MRI-based ENZIAN classification (Haas et al., 2013a). ...
Background:
In the field of endometriosis, several classification, staging and reporting systems have been developed. However, endometriosis classification, staging and reporting systems that have been published and validated for use in clinical practice have not been systematically reviewed up to now.
Objectives:
The aim of the current review is to provide a historical overview of these different systems based on an assessment of published studies.
Materials and methods:
A systematic Pubmed literature search was performed. Data were extracted and summarised.
Results:
Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific and different purposes. There is still no international agreement on how to describe the disease. Studies evaluating different systems are summarised showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the Enzian system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.
Conclusions:
Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes.
What is new?:
This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.
... In addition, several studies have demonstrated that the Enzian classification, be it surgical or with TVS/MRI, can be used to estimate operation time, help to choose adequate surgical techniques preoperatively and to estimate the risk of associated complications [36]. Roman et al. [48] compared the outcome after surgery for bowel endometriosis (according to the size of the nodule) with two different surgical approaches. ...
Endometriotic lesions may affect peritoneal and ovarian tissues, cause secondary adhesions and does - in case of deep endometriosis (DE), invade organs such as the urinary bladder, ureters and bowel. Over decades, several classification systems have been proposed with the rASRM score being the most widely accepted one to date. However, the rASRM classification has certain limitations regarding the description of DE. In contrast, the Enzian classification, which has been updated and modified recently in form of the so-called #Enzian classification has proved to be the most suitable tool for staging DE and does now also include peritoneal or ovarian disease as well as adhesions. In the ideal scenario, a classification for endometriosis can be used with both, diagnostic and surgical methods. The present work discusses the pros and cons of scores for endometriosis and will highlight the need for using one universal classification system.
... Analog zur TNM-Klassifikation macht sie eine genaue Aussage über die anatomische Situation und kann so bei der Operationsplanung helfen. Mittels MRI-basierter Enzian-Klassifikation kann man das Resektionsausmass und die Operationsdauer besser abschätzen [17]. In einer Studie konnte gezeigt werden, dass bei einer C1-Läsion (Rektumläsion <1 cm) in 71,4 % die Läsion allein exzidiert Abbildung 2. Enzian-Klassifikation (Darstellung nach [5] Die präoperativ anhand der MRI-Bildgebung eingesetzte Enzian-Klassifikation scheint gut mit den defini tiven intraoperativen Befunden übereinzustimmen. ...
Zusammenfassung. Obwohl die Endometriose zu den häufigen gynäkologischen Krankheitsbildern der Frau im reproduktionsfähigen Alter zählt, erfolgen die Diagnose und der Therapiebeginn häufig spät nach Beginn der Symptomatik. Die Erklärung liegt wahrscheinlich einerseits in der mannigfaltigen Ausprägung, den diffusen Beschwerden und der leider eher geringen Bekanntheit dieses Krankheitsbildes. Andererseits stellt die Diagnostik selbst eine Herausforderung dar. Insbesondere die tief infiltrierende Form der Endometriose ist schwerwiegend, bei welcher häufig eine chirurgische Therapie notwendig wird. Eine systematische Herangehensweise mit MRI-Bildgebung und präoperativer Einteilung mittels Enzian-Klassifikation kann das Vorgehen erleichtern und die Therapieplanung vereinfachen.
... Moreover, our study demonstrated that both MRI-based Enzian and dPEI classifications helped predict operating time which is related to the extension of the disease. This is in line with previous reports from Haas et al. (2013), that underlined a major impact of colorectal lesion size on the length of procedure. Furthermore, Mabrouk et al. (2019) described longer surgery in patients with lateral pelvic endometriosis, as distal parametrial involvement may indicate parametrectomy with uncrossing of distal ureter and uterine artery which undoubtedly lengthens the intervention. ...
Study question:
Is an MRI classification of deep pelvic endometriosis (DE) able to correctly predict the risk of DE surgery.
Summary answer:
A new radiological classification, that we have called the deep pelvic endometriosis index (dPEI) classification, is accurate and reproducible to assess the extension of the disease in central and lateral compartments and well correlated with operating time, hospital stay duration and the risk of voiding dysfunction.
What is known already:
Few imaging classifications are currently available to predict the extent of DE to help preoperative assessment of surgical outcomes and provide the patient with objective information about the risk of surgical complications.
Study design, size, duration:
Retrospective monocentric observational study was conducted between 01 January 2017 and 31 December 2018 and included 150 women (mean age = 34.5 years, 20-52 years) with DE on MRI and who subsequently underwent surgery.
Participants/materials, setting, methods:
Two radiologists independently graded the disease according to MRI-based Enzian classification (A (rectovaginal septum and vagina locations), B (uterosacral locations) and C (rectosigmoid locations)) and a new radiological classification, that we have called the dPEI, that grades the severity of DE as: mild, moderate or severe DE. MRI findings and classification were correlated with surgical and pathological results.
Main results and the role of chance:
MRI-based and surgical Enzian classifications were concordant for A lesions in 78.7% (118/150), for B lesions in 34.7% (52/150) and for C lesions in 82.7% (124/150). Operating time and hospital stays were longer in Group A2 (rectovaginal septum and vagina, 1-3 cm) compared to A0, B2 (uterosacral, 1-3 cm) compared to B0, C3 (rectosigmoid >3 cm) compared to C2 (rectosigmoid 1-3 cm) or C0 (P < 0.001), in severe compared to moderate DE patients, and in moderate compared to mild extensive patients (P < 0.01). Patients with vaginal or rectosigmoid involvement were respectively six and three times more likely to experience high-grade complications according to Clavien-Dindo classification than patients without vaginal or rectosigmoid disease (P < 0.001). Postoperative voiding dysfunction was correlated with A lesions (odds ratio (OR) = 6.82, 95% CI 2.34-20.5), moderate or severe DE (OR = 4.15, 95% CI 1.26-17.9), the presence of at least unilateral lateral pelvic involvement (OR = 3.6, 95% CI 1.14-11.2, P = 0.03) and C lesions (OR = 2.6, 95% CI 1.03-6.8, P < 0.01).
Limitations, reasons for caution:
The study was conducted in an expert center and needs to be validated in a multicenter study. There is a limited number of patients with lateral pelvic endometriosis beyond the parietal fascia, probably due to the low prevalence of this disease presentation.
Wider implications of the findings:
MRI imaging can be used to accurately predict postoperative complications for women with DE. This may help the clinician to preoperatively inform a patient about the risks of surgery. Larger clinical studies are required to validate these results.
Study funding/competing interest(s):
No external funding was used for this study. I.T.N.: Remunerated lecture GE, Hologic, Guerbet, Canon; Advisory board: Siemens - These relationships are on the topic of breast imaging, not related to the topic of this paper. Other coauthors have no conflict of interest to declare.
Trial registration number:
Not applicable.
... Several systems classifying and documenting the extent of the DE have been developed, including the ENZIAN classification (Keckstein et al., 2003b;Tuttlies et al., 2005; Stiftung Endometriose Forschung (Foundation for Endometriosis Research), 2011) (Fig. 3), the Visual Numeric Endometriosis Surgical Score (VNESS) system (Abdalla AL and S., 2015) and those proposed by Chapron et al. and Adamyan (Adamyan, 1993;Chapron et al., 2003). The ENZIAN classification showed a significant correlation between the extent of the disease, difficulty and length of surgery and symptoms (Haas et al., 2013a;Haas et al., 2013b; ing systems with their advantages and disadvantages are summarised in Table I. In addition to classifying endometriosis, the documentation of surgical findings, such as in Endometriosis Fertility Index (EFI), has been found to have a prognostic value in infertile women (Adamson and Pasta, 2010;Adamson, 2013). ...
STUDY QUESTION
How should surgery for endometriosis be performed?
SUMMARY ANSWER
This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.
WHAT IS KNOWN ALREADY
Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.
STUDY DESIGN, SIZE, DURATION
A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.
PARTICIPANTS/MATERIALS, SETTING, METHODS
This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.
MAIN RESULTS AND THE ROLE OF CHANCE
The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.
LIMITATIONS, REASONS FOR CAUTION
Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.
WIDER IMPLICATIONS OF THE FINDINGS
These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.
STUDY FUNDING/COMPETING INTEREST(S)
The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.
TRIAL REGISTRATION NUMBER
na
... One critical aspect is e.g. the occurrence of duplicate scoring of lesion between rASRM and ENZIAN staging systems thus ENZIAN is in its current version not a complementation of the rASRM system. Its revisions simplified the scoring system and enhanced its benefit for staging deep infiltrating retroperitoneal endometriosis but it still lacks poor international acceptance [122][123][124][125]. ...
Background
A substantial body of studies supports the view that molecular and cellular features of endometriotic lesions differ from those of eutopic endometrium. Apart from that, evidence exists that the eutopic endometrium from pa-tients with endometriosis differs from that of females without endometriosis.
Objective
Aberrant expression profiles include a number of non-steroid signaling pathways that exert their putative influ-ence on the pathogenesis of endometriosis at least in part via crosstalk(s) with estrogen-mediated mechanisms. A rational to focus research on non-steroid signal pathways is that they might be remunerative targets for the development and selection of novel therapeutics to treat endometriosis possibly without affecting estrogen levels.
Results and Conclusion
In this article, we describe molecular and cellular features of endometriotic lesions and focus on the canonical WNT/β-signaling pathway, a key regulatory system in biology (including stem cell homeostasis) and often in pathophysiological conditions such as endometriosis. Recently emerged novel biological concepts in signal transduction and gene regulation like exosomes and microRNAs are discussed in their putative role in the pathogenesis of endometriosis.
... The revised American Society for Reproductive Medicine (rASRM) score is currently the best-known and most widely used classification of endometriosis. It is relatively easy to utilize, but it does not take into account the involvement of retroperitoneal structureswith deeply infiltrating endometriosis (10) . On the other hand, advantages of the Enzian classification (frequently used in German-speaking countries) include the fact that the location and extent of involved retroperitoneal structures can be described with relative morphological precision. ...
Endometriosis is a benign disease with highly variable symptoms. The adequate treatment for symptomatic disease requires complete resection of all lesions. In advanced stages, bowel involvement is common. However, indications of colorectal resection for endometriosis remain controversial because of the risk of major complications. The aim of this study was to assess the feasibility of complete laparoscopic management of symptomatic deep pelvic endometriosis in a new multidisciplinary center in Romania. We included and retrospectively evaluated 74 patients treated for symptomatic deep infiltrating endometriosis in our institution between 2014 and 2015. In the majority of patients (97.3%), radical resection was achieved entirely using a minimally invasive surgical technique. Complications occurred in only 2 cases with anastomotic leakage in 1 patient and a rectovaginal fistula in another patient. A well-trained interdisciplinary team can perform the laparoscopic treatment of deep infiltrating endometriosis with low incidence of major complications and good clinical outcome. © 2016 Romanian Society of Ultrasonography in Obstetrics and Gynecology.
... Enzian classification and rASRM score supplement each other in terms of morphological description and have common potential for classifying endometriosis. Preoperative staging permits the creation of a treatment plan and provides an early stage prognosis [26,[32][33][34][35]. ...
Endometriosis is categorized as one of the chronic benign gynecologic diseases, which causes pelvic pain and infertility, affecting almost 10% of reproductive-age women. Deeply infiltrating endometriosis (DIE) is a specific entity of endometriosis, responsible for painful symptoms, which are related to the anatomic location of the lesions. In this paper, we aim to review the current literature regarding the post-surgery quality of life improvement for DIE. Irrespective of its low sensitivity and specificity, vaginal examination and evaluation of specific symptoms should be emphasized as a basic diagnostic tool in detecting endometriosis. This will help in planning further DIE related therapeutic interventions. Out of several, transvaginal ultrasound (TVUS) has been reported as one of the widely used and excellent tools to diagnose DIE lesions in different locations (rectovaginal septum, retrocervical and paracervical areas, rectum and sigmoid and vesical wall).
... The description of retroperitoneal and deep infiltrating growth forms is also inadequate with this system. The Endometriosis Research Foundation has attempted to overcome this shortcoming by creating an appropriate classificationthe ENZIAN classification [77,79,80,157,186]. Like the rASRM score, the ENZIAN classification is also morphologically descriptive. ...
In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.
Deep endometriosis (DE) surgery often requires advanced knowledge in laparoscopic surgery due to the location of affected organs such as the bowel, vagina, rectovaginal space including adjacent nerve structures, ureters and urinary bladder. Patients are at risk of serious complications and sequelae like anastomotic leakage, rectovaginal fistula and voiding dysfunction. Detailed knowledge of disease extent and location by transvaginal sonography (TVS) can aid the clinician to pre-operatively plan complex surgeries and estimate associated risks. Classification systems like #Enzian can be used in combination with TVS to assess surgical risk factors.
Classification of the disease has been used primarily for the postoperative staging of the disease. Unfortunately, the most commonly used rASRM classification does not correlate with symptoms or other important parameters, and cannot be used for non-invasive diagnostics. Moreover, it does not take into account deep infiltrating endometriosis but also extra pelvic endometriosis. The EFI is for calculating the probability of pregnancy but does not contain differential information on the location and extent of lesions. The ENZIAN classification is predominantly used to describe DE. The applicability of the Enzian classification with MRI and TVS is possible and allows to assess the difficulty of the surgical procedure and the risk of surgery. The recently released updated version, called the #ENZIAN classification, represents a comprehensive description of peritoneal and ovarian endometriosis as well as adnexal adhesions in addition to deep endometriosis. This system is anatomically logical, easy to use, and more reproducible, providing the physician with a clear picture of the disease. The good correlation between the non-invasive and surgical description of the extent of the disease based on the #Enzian scheme provides a consistent and clear classification of endometriosis, especially DE, but also secondary adhesions.
Objectives Endometriosis is a chronic disease which is diagnosed by surgical intervention combined with a histological work-up. Current international and national recommendations do not require the histological determination of the proliferation rate. The diagnostic and clinical importance of the mitotic rate in endometriotic lesions still remains to be elucidated.
Methods In this retrospective study, the mitotic rates and clinical data of 542 patients with histologically diagnosed endometriosis were analyzed. The mean patient age was 33.5 ± 8.0 (17 – 72) years, and the mean reproductive lifespan was 21.2 ± 7.8 (4 – 41) years. Patients were divided into two groups and patientsʼ reproductive history and clinical endometriosis characteristics were compared between groups. The study group consisted of women with confirmed mitotic figures (n = 140, 25.83%) and the control group comprised women without proliferative activity according to their mitotic rates (n = 402, 74.27%).
Results Women with endometriotic lesions and histologically confirmed mitotic figures were significantly more likely to have a higher endometriosis stage (p = 0.001), deep infiltrating endometriosis (p < 0.001), ovarian endometrioma (p = 0.012), and infertility (p = 0.049). A mitotic rate > 0 was seen significantly less often in cases with incidental findings of endometriosis (p = 0.031). The presence of symptoms and basic characteristics such as age, age at onset of menarche, reproductive lifespan and parity did not differ between the group with and the group without mitotic figures.
Conclusion This study shows that a simple histological assessment of the mitotic rate offers additional diagnostic value for the detection of advanced stages of endometriosis. The possible role as a predictive marker for the recurrence of endometriosis or the development of endometriosis-associated cancer will require future study.
STUDY QUESTION
Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice?
SUMMARY ANSWER
Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed.
WHAT IS KNOWN ALREADY
In the field of endometriosis, several classification, staging and reporting systems have been developed.
PARTICIPANTS/MATERIALS, SETTING, METHODS
A systematic PUBMED literature search was performed. Data were extracted and summarized.
MAIN RESULTS AND THE ROLE OF CHANCE
Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.
LARGE SCALE DATA
NA.
LIMITATIONS, REASONS FOR CAUTION
The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered.
WIDER IMPLICATIONS OF THE FINDINGS
It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working toward a universally accepted endometriosis classification.
STUDY FUNDING/COMPETING INTEREST(S)
The meetings and activities of the working group were funded by the American Association of Gynecologic Laparoscopists, European Society for Gynecological Endoscopy, European Society of Human Reproduction and Embryology and World Endometriosis Society. A.W.H. reports grant funding from the MRC, NIHR, CSO, Wellbeing of Women, Roche Diagnostics, Astra Zeneca, Ferring, Charles Wolfson Charitable Trust, Standard Life, Consultancy fees from Roche Diagnostics, AbbVie, Nordic Pharma and Ferring, outside the submitted work. In addition, A.W.H. has a patent Serum biomarker for endometriosis pending. N.P.J. reports personal fees from Abbott, Guerbet, Myovant Sciences, Vifor Pharma, Roche Diagnostics, outside the submitted work; he is also President of the World Endometriosis Society and chair of the trust board. S.M. reports grants and personal fees from AbbVie, and personal fees from Roche outside the submitted work. C.T. reports grants, non-financial support and other from Merck SA, non-financial support and other from Gedeon Richter, non-financial support from Ferring Pharmaceuticals, outside the submitted work and without private revenue. K.T.Z. reports grants from Bayer Healthcare, MDNA Life Sciences, Roche Diagnostics Inc, Volition Rx, outside the submitted work; she is also a Board member (Secretary) of the World Endometriosis Society and World Endometriosis Research Foundation, Research Advisory Board member of Wellbeing of Women, UK (research charity), and Chair, Research Directions Working Group, World Endometriosis Society. The other authors had nothing to disclose.
TRIAL REGISTRATION NUMBER
NA.
Objective
In the field of endometriosis, several classification, staging and reporting systems have been developed. Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice?
Data sources
A systematic PUBMED literature search was performed. Data were extracted and summarized.
Methods of study selection
na
Tabulation, integration and results
Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.
Conclusion
Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated for the purpose for which they were developed. The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.
Introduction:
This study evaluates the clinical utility of magnetic resonance imaging (MRI) for the determination of presence and extent of DIE with special emphasis on effects of MRI reporting training MATERIAL AND METHODS: Data from 80 patients with clinically suspected DIE presented at our certified endometriosis center between 2015 and 2018 were analyzed. For all patients an ENZIAN score (describing DIE related to individual anatomical localizations) was obtained based on the preoperative MRI findings. The intraoperatively determined ENZIAN score served as the reference for assessment of diagnostic performance of the MRI.
Results:
Overall, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of DIE by MRI were 76.9%, 53.3%, 87.7% and 34.8%, respectively. Analysis by compartment revealed a sensitivity, specificity, PPV and NPV of 59.5%, 88.2%, 86.2% and 63.9%, respectively, for compartment A, with similar values for compartment B, and 50.0%, 88.9%, 64.7% and 81.4%, respectively, for the less often affected compartment C. Expert training (n = 32 before, n = 48 after) led to a considerable increase in sensitivities for the overall detection of DIE (84.6% vs. 65.4%, p = 0.071) and for the detection of DIE in compartment A (71.4% vs. 35.7%, p = 0.026), compartment B (66.7% vs. 37.5%, p = 0.057) and compartment C (75.0% vs. 20.0%, p = 0.010), without significant loss in specificity (all p > 0.50).
Discussion:
After expert training, MRI has a good sensitivity with fair specificity regarding preoperative assessment of presence, location and extent of DIE.
Advances in preoperative diagnostic as well as surgical techniques for the treatment of endometriosis, especially deep endometriosis call for a classification system that includes all aspects of the disease such as peritoneal, ovarian endometriosis and deep endometriosis and secondary adhesions. The widely accepted r‐ASRM classification has certain limitations due to its incomplete description of deep endometriosis. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable tool for staging deep endometriosis but does not include peritoneal or ovarian disease as well as adhesions. To overcome these limitations, a comprehensive classification system for complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions and degree of involvement of the adjacent organs that can be used with both, diagnostic and surgical methods, has been created via a consensus process and will be described in detail ‐ the #Enzian classification.
The classification of adolescent endometriosis is critical to research efforts and improvements in available therapies. A review of the existing systems reveals strengths and limitations, including the absence of pain as a symptom of disease. A novel system should be developed and validated, particularly with regard to the adolescent population.
Résumé
Objectif
La prise en charge chirurgicale de l’endométriose peut relever de différents niveaux de compétences ce qui influe sur l’orientation des patientes. Le score échographique UBESS (Ultrasound-Based Endometriosis Staging System) est un score échographique récent permettant de prédire cette difficulté. L’Objectif était d’étudier le degré de corrélation entre UBESS et les deux principales classifications chirurgicales de la littérature.
Méthodes
Étude réalisée au centre de Poissy entre juillet 2016 et décembre 2017. Étaient incluses toutes patientes ayant bénéficié d’une stadification UBESS en prospectif puis opérées de leur endométriose. Les patientes étaient classées selon les niveaux de difficulté chirurgicale du Royal College of Obstetricians and Gynaecologists (RCOG) et de la classification de Chi et al. Le critère de jugement était la corrélation entre les stades UBESS et les niveaux de RCOG et CHI. En seconde analyse, il était déterminé la valeur prédictive du plan opératoire des items de l’examen échographique décrit par Menakaya et al.
Résultats
Trente-trois patientes ont été incluses. La corrélation de UBESS était faible avec RCOG (θ = 0,22) et CHI (θ = 0,30). La prédiction du plan opératoire était bonne pour l’endométriome, les sites douloureux spécifiques, le signe du glissement, l’atteinte vaginale et digestive, mais modeste pour l’atteinte antérieure et utérosacrée.
Conclusion
Dans notre étude sur un petit effectif, le score UBESS ne prédit pas de façon satisfaisante la difficulté chirurgicale. Pris séparément, les différents items de l’exploration échographique systématisée en 5 étapes, prédisent convenablement le plan opératoire.
The aim of the present review was to evaluate the contribution of clinical examination and imaging techniques, mainly transvaginal sonography and magnetic resonance imaging (MRI) to diagnose deep infiltrating (DE) locations using prisma statement recommendations. Clinical examination has a relative low sensitivity and specificity to diagnose DE. Independently of DE locations, for all transvaginal sonography techniques a pooled sensitivity and specificity of 79% and 94% are observed approaching criteria for a triage test. Whatever the protocol and MRI devices, the pooled sensitivity and specificity for pelvic endometriosis diagnosis were 94% and 77%, respectively. For rectosigmoid endometriosis, pooled sensitivity and specificity of MRI were 92% and 96%, respectively fulfilling criteria of replacement test. In conclusion, advances in imaging techniques offer high sensitivity and specificity to diagnose DE with at least triage value and for rectosigmoid endometriosis replacement value imposing a revision of the concept of laparoscopy as the gold standard.
Objective:
To investigate whether pelvic examination may be meaningfully taught to novice medical students and its accuracy in predicting operating times for laparoscopic excision of endometriosis at a single surgical procedure.
Methods:
Women with suspected endometriosis scheduled for laparoscopy underwent pelvic examination to estimate operative time by medical students (novices), trainees, senior clinicians with <10 years surgical experience (experts) and ≥10 years (masters). Examination and intraoperative findings were compared and stage of disease recorded.
Results:
There were 138 estimations of operating time at the initial assessment and 251 estimations of operating time prior to surgery. The median surgical duration was 44 min (range 12-398) and increased progressively with revised American Society for Reproductive Medicine disease stage. Clinical predictions exceeded actual operating times by a median of 18 min (range overestimating by 180 min and underestimating by 120 min) with 80% of procedures completed in less time than predicted and none requiring a second procedure. There was no statistical difference in operative time estimations between the groups with students and trainees underestimating surgical duration by a median of two and five minutes, respectively, experts having a median time difference of zero minutes, and masters overestimating by 4.5 min.
Conclusion:
Targeted pelvic examining may be taught to novices (medical students) and can be used to predict operating time at one surgical procedure. Less experienced examiners have a tendency to underestimate surgical duration, with masters overestimating surgical time when scheduling laparoscopies for endometriosis, and increasing disease stage is associated with a less precise estimation of surgical duration.
3.1 Definition and epidemiology
Statements:
Endometriosis – one of the most common gynecologic diseases – is defined as the occurence of endometrium-like cell formations outside the uterine cavity.
The cardinal symptom is chronic pelvic pain. Infertility is common.
There are about 20 000 hospital admissions per year for endometriosis in Germany (Haas et al. 2012). Pathologically and histologically, endometriosis is a benign disease. However, infiltrative growth into adjacent organs is possible requiring extensive surgical procedures.
The revised American Society for Reproductive Medicine (rASRM) score is currently the best-known classification of endometriosis and is the one most widely used throughout the world. It is relatively easy to use, but it does not take into account the involvement of retroperitoneal structures with deeply infiltrating endometriosis. For this reason, the Enzian classification was developed as a supplement to the rASRM score, in order to provide a morphologically descriptive classification of deeply infiltrating endometriosis. The Enzian classification currently has a poor level of international acceptance and is mainly used in the German-speaking countries. It was revised in 2011 and is now also easier to use. This article describes the strengths and weaknesses of the rASRM score and the Enzian classification and their common potential for classifying endometriosis.
The purpose of this study was to assess the operating time of the most common gynaecological laparoscopic procedures. We analysed
retrospectively 1000 consecutive operative laparoscopies on a procedure-by-procedure basis. Diagnostic laparoscopy and laparoscopic
sterilization were specifically excluded from the analysis. The various laparoscopic procedures were grouped and analysed
under six major categories. The average operating time for all cases was 76.9 min (range 10–400). In 38 cases (3.8%) the laparoscopic
procedure was converted to laparotomy. The average operating time for treating ectopic pregnancy and tubal disease was approximately
60 min (range 13–240). Surgery for endometriosis and ovarian cysts averaged 72 min (range 10–240). Laparoscopic myomectomy
and hysterectomy averaged 113 and 131 min respectively (range 25–400). Our results show that while the operating time for
most operative laparoscopies is less than 75 min, the range of operating times is great. The relative lack of predictability
in procedure times means that the efficient utilization of fixed theatre sessions is difficult.
The ENZIAN-Score is presented as a new instrument to classify the deep infiltrating endometriosis. Especially the retroperitoneal part of the severe endometriosis is focussed on. In analogy to an oncological staging four different stages are pronounced. The localisation and the expansion of the endometriosis nodule was indicated to different subgroups. The still used rAFS-score is of no clinical evidence, as we pointed out in a retrospective study of our patients with severe intestinal endometriosis.
The serious, though unusual, hemorrhage of ovarian origin into the peritoneal cavity simulating ruptured tubal pregnancy is well known to every abdominal surgeon, even though he may have encountered but few such instances in his own practice. The literature on this subject has been recently reviewed by Novak¹ and by Smith.² The larger ovarian cysts, also with hemorrhagic contents due to twisting of the pedicle of the cyst or from other conditions, are so obvious as to make it impossible to overlook them. Ovarian hematomas due to various causes have been reported by Savage, ³ Wolf, ⁴ Hedley, ⁵ Novak ⁶ and others.
There is, however, one type of hemorrhagic ovarian cyst or ovarian hematoma which should receive more careful attention; not only on account of its frequency but because of the nature of the adhesions resulting from the escape of its contents into the peritoneal cavity. These
Endometriosis remains an enigmatic disease for many reasons, not the least being a continued inability to stage its clinical presentation so that prognosis and treatment for both pain and infertility patients can be facilitated. This article reviews issues with current staging systems.
The revised American Fertility Society (rAFS) classification system has historically been the only classification system. Recently, the ENZIAN classification system, developed as an adjunct to the rAFS to describe more severe disease, has been introduced but is rarely used. More recently, the Endometriosis Fertility Index (EFI) that has been validated to predict pregnancy rates in infertility patients following surgical diagnosis and treatment of endometriosis was published. Currently, the AAGL is developing a categorization system that will be more focused on pain. Novel research in imaging, biomarkers, histology, and the human genome may provide useful information to develop future classification systems.
The only validated endometriosis classification system that predicts a clinical outcome is the EFI. It is to be hoped that renewed interest in the importance and utility of classification systems will result in novel classification systems that are clinically useful.
The aim of this study was to compare the diagnostic performance of clinical vaginal examination with that of transvaginal sonography (TVS) in the presurgical diagnosis of deep infiltrating endometriosis.
One-hundred and fifty-five women with symptoms suggestive of endometriosis were included. One-hundred and twenty-nine patients met the inclusion criteria and were prospectively and independently assessed by vaginal examination and TVS prior to a diagnostic laparoscopy and, where appropriate, radical resection and histological confirmation of endometriosis was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and positive and negative likelihood ratios (LR+ and LR-) were calculated for each test method.
In total, 83 (64%) women had histological confirmation of endometriosis, 52 (40%) of whom had deep infiltrating endometriosis. The prevalence of endometriosis on the uterosacral ligaments, pouch of Douglas, vagina, bladder, rectovaginal space and rectosigmoid was 23.3%, 16.3%, 8.5%, 3.1%, 6.9% and 24%. PPV, NPV, LR+ and LR- for vaginal examination were 92%, 87%, 41.56 and 0.60 for ovarian endometriosis; 43%, 84%, 2.48 and 0.63 for uterosacral ligament disease; 64%, 95%, 9.14 and 0.26 for involvement of the pouch of Douglas; 80%, 97%, 42.91 and 0.28 for vaginal endometriosis; 78%, 98%, 46.67 and 0.23 for endometriosis of the rectovaginal space; 100%, 98%, 75.60 and 0.75 for bladder involvement; 86%, 84%, 18.97 and 0.63 for rectosigmoidal endometriosis. Values for TVS were similar with regard to vaginal and rectovaginal space endometriosis, but were clearly superior to vaginal examination in cases of ovarian (87%, 99%, 24.56 and 0.04), uterosacral ligament (91%, 90%, 31.35 and 0.37) and rectosigmoidal (97%, 97%, 88.51 and 0.1) endometriosis.
TVS is a more useful test than is vaginal examination in detecting endometriosis in the ovaries and rectosigmoid.
Modern imaging techniques allow for the noninvasive diagnosis of endometriosis. Preoperative staging of pelvic endometriosis helps the gynecologist plan therapy and offer a prognosis to patients. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome, or aid in the management of pelvic pain, is recognized to be inadequate. The study of deeply infiltrating endometriosis and adenomyosis is greatly hampered by a lack of clear terminology and the absence of a consensus classification of the lesions. A reviewed consensus classification of endometriosis in general, with a more detailed consideration on deep endometriosis, is urgently required. We suggest a new staging system for deep, infiltrating endometriosis based on ultrasonographic findings. Prospective data collection and review in large centers may provide a larger clinical base from which to derive empirical point scores and breakpoints in the classification scheme.
To develop a classification that takes deep infiltrating endometriosis into account, the ENZIAN score was introduced. The ENZIAN classification supplements the revised American Fertility Society (AFS) score with regard to the description of deep infiltrating endometriosis, retroperitoneal structures, and other organs. The null hypothesis was that classifying a lesion by the revised AFS as well as the ENZIAN system is not meaningful, because the two systems express different locations.
Retrospective.
Hospital admissions.
Two hundred nineteen women admitted for endometriosis.
Surgical interventions.
Classification of the severity of endometriosis according to the revised AFS and the ENZIAN classification, focusing on the distribution pattern in deep infiltrating endometriosis, and the identification of duplicate classifications of the same lesions in the revised AFS as well as the ENZIAN systems.
Deep infiltrating endometriosis was diagnosed in 160 of 219 patients (73%). These patients had 236 lesions of deep infiltrating endometriosis, which were classified by ENZIAN as follows: compartment a (vertical): 26%; compartment b (horizontal): 41%; compartment c (dorsal): 24%; uterine adenomyosis: 4%; bladder disease: 2%; ureter disease: 1%; and bowel disease: 2%. The severity of deep infiltrating endometriosis according to ENZIAN (grades 1 = mild to 4 = severe) was as follows: grade 1: 45%; grade 2: 26%; grade 3: 19%; grade 4: 10%. Fifty-eight patients were classified according to ENZIAN although they did not fulfill the criteria of deep infiltrating endometriosis and had previously been classified according to the revised AFS classification. Adaptation of the ENZIAN score would reduce the diagnoses of deep infiltrating endometriosis by 36% (95% confidence interval [CI] 29%-44%).
The ENZIAN score is a helpful aid to describe deep infiltrating endometriosis, but needs to be adapted.
To develop a clinical tool that predicts pregnancy rates (PRs) in patients with surgically documented endometriosis who attempt non-IVF conception.
Prospective data collection on 579 patients and comprehensive statistical analysis to derive a new staging system--the endometriosis fertility index (EFI)--from data rather than a priori assumptions, followed by testing the EFI prospectively on 222 additional patients for correlation of predicted and actual outcomes.
Private reproductive endocrinology practice.
A total of 801 consecutively diagnosed and treated infertile patients with endometriosis.
Surgical diagnosis and treatment followed by non-IVF fertility management.
The EFI and life table PRs.
A statistically significant variable used to create the EFI was the least function score (i.e., the sum of those scores determined intraoperatively after surgical intervention that describe the function of the tube, fimbria, and ovary on both sides). Sensitivity analysis showed that the EFI varies little, even with variation in the assignment of functional scores, and predicted PRs.
The EFI is a simple, robust, and validated clinical tool that predicts PRs after endometriosis surgical staging. Its use provides reassurance to those patients with good prognoses and avoids wasted time and treatment for those with poor prognoses.
To compare the value of physical examination, transvaginal sonography (TVS), rectal endoscopic sonography (RES), and magnetic resonance imaging (MRI) for the assessment of different locations of deep infiltrating endometriosis (DIE).
Retrospective longitudinal study.
Tertiary university gynecology unit.
Ninety-two consecutive patients with clinical evidence of pelvic endometriosis.
Physical examination, TVS, RES, and MRI, performed preoperatively.
Descriptive statistics, calculation of likelihood ratios (LR(+) and LR(-)) of physical examination, TVS, RES, and MRI for DIE in specific locations confirmed by surgery/histology.
The sensitivity and LR(+) and LR(-) values of physical examination, TVS, RES, and MRI were, respectively, 73.5%, 3.3, and 0.34, 78.3%, 2.34, and 0.32, 48.2%, 0.86, and 1.16, and 84.4%, 7.59, and 0.18 for uterosacral ligament endometriosis; 50%, 3.88, and 0.57, 46.7%, 9.64, and 0.56, 6.7%, -, and 0.93, and 80%, 5.51, and 0.23 for vaginal endometriosis; and 46%, 1.67, and 0.75, 93.6%, -, and 0.06, 88.9%, 12.89, and 0.12, and 87.3%, 12.66, and 0.14 for intestinal endometriosis.
The MRI performs similarly to TVS and RES for the diagnosis of intestinal endometriosis but has higher sensitivity and likelihood ratios for uterosacral ligament and vaginal endometriosis.
The visual diagnosis of endometrioma at laparotomy in 245 women operated on for ovarian cysts demonstrated a sensitivity of 97%, specificity of 95%, positive and negative predictive value of 98% and 94%, respectively, and overall accuracy of 96%. Because the visual detection of endometriomas is remarkably accurate, ovarian biopsy, although desirable in some cases, would seem dispensable for a correct laparoscopic diagnosis and staging of the disease.
A review of the literature reveals no useful means by which reasonable prognosis can be rendered to an infertile patient who has had conservative surgical therapy of endometriosis. Based on a study of 107 infertile patients who underwent conservative operative treatment of endometriosis, a practical classification of endometriosis has been devised to establish the likelihood for subsequent conception. A definite correlation was demonstrated between these factors and the probability of conceiving. © 1973 The American College of Obstetricians and Gynecologists.
To assess the reproducibility in staging endometriosis using the revised American Fertility Society (AFS) classification of endometriosis.
Visual documentation of laparoscopies of 315 women with endometriosis was scored by the investigators and a blinded reviewer.
Patients from private practice institutional setting.
Patients who participated in a multicenter trial to study the efficacy and safety of a GnRH agonist (GnRH-a).
Laparascopic visual documentation of the extent of endometriosis before and after 6 months of GnRH-a therapy.
The reproducibility of the AFS classification system comparing scoring during laparoscopy and by a blinded reviewer.
Good to fair agreement scoring endometriosis between the investigator and the blinded reviewer was noted.
Visual documentation may be used to determine the stage of endometriosis using the revised AFS classification guidelines.
To compare the surgical management and follow-up of patients with endometriomas managed by endoscopic surgery versus laparotomy using a retrospective case control format.
Endoscopic oophorocystectomies were performed on 36 patients. Chart review of laparotomy oophorocystectomies from 21 patients was conducted. Six-week and 12-month follow-up for evaluation of symptoms, evidence of recurrence, and fertility was available on all subjects.
In the endoscopy group, 39 patients had screening laparoscopy for possible endoscopic surgery. Three of this group required laparotomy and 36 patients underwent endoscopic surgery. Chart review identified 21 patients who had undergone primary laparotomy for endometriomas. Patient groups were matched for age, severity of disease, presence of other infertility factors, and absence of perioperative medical suppression. Outcome parameters for each group were: operating time--endoscopy 2.8 hours (+/- 1.2), laparotomy 3.1 hours (+/- 1.8); estimated blood loss--endoscopy 40 cc (+/- 45); laparotomy, 240 cc (+/- 107); recovery time--endoscopy, 6.2 days (+/- 2.5), laparotomy 30 days (+/- 6.8); endometrioma recurrence rate--endoscopy 11.1%, laparotomy 19%; and pregnancy rate--endoscopy 42.8%, laparotomy 46.6%.
A high percentage of patients with endometriomas associated with advanced endometriosis can be managed effectively by endoscopic surgery.
To assess the degree of intraobserver and interobserver variability in endometriosis staging using the revised American Fertility Society (AFS) classification of endometriosis.
Videotapes of laparoscopies of 20 patients with endometriosis were each scored twice by five observers.
The reproductive endocrine unit of a tertiary care, university-affiliated hospital.
Five subspecialty-certified reproductive endocrinologists.
None.
Variability in assigned score was measured for each of the five components of the AFS classification, as well as total scores and stage of endometriosis.
There was considerable variability in the scores assigned to each videotape, both by the same observer and by different observers. The grand total score, which ranged from 0 to 90, varied with an SD of 13.44 when a single patient was rated twice by the same observer and varied with an SD of 17.12 when a single patient was rated by two different observers. Among individual components of the score, the greatest variability occurred in endometriosis of the ovary and cul-de-sac obliteration, with less variability observed for peritoneum endometriosis and for ovarian and tubal adhesions. Comparison of intraobserver and interobserver scores resulted in a change in endometriosis stage in 38% and 52% of patients, respectively. There were statistically significant differences in mean endometriosis scores among the observers in four of the five anatomic categories examined.
Intraobserver and interobserver variability was high for ovarian endometriosis and cul-de-sac subscores using the revised AFS classification of endometriosis.
To determine whether prevalence and severity of pain symptoms are related to endometriosis stage and site, with particular reference to deep infiltrating vaginal lesions.
Systematic assessment of chronic pelvic pain symptoms.
University hospital endometriosis center.
A total of 244 consecutive symptomatic patients with endometriosis diagnosed at laparoscopy or laparotomy.
Assessment of dysmenorrhea and nonmenstrual pain by means of a 10-point linear analog scale, a 7-point multidimensional rating scale, and a 3-point verbal scale; evaluation of deep dyspareunia with the first and third systems only.
Prevalence and severity of pain symptoms in relation to endometriosis stage and site of lesions. Correlation between revised American Fertility Society score and symptoms severity, as well as between two pain scales to assess dysmenorrhea and nonmenstrual pain.
Eighty-eight women had stage I and II disease and 156 had stage III and IV disease. Only ovarian endometriosis was present in 108 patients, only peritoneal implants were present in 37, combined ovarian and peritoneal lesions were present in 57, and histologically confirmed vaginal endometriosis was present in 42. The frequency and severity of deep dyspareunia and the frequency of dysmenorrhea were less in patients with only ovarian endometriosis than in those with lesions at other sites. Patients with vaginal endometriosis had a significantly increased risk of deep dyspareunia compared with those whose lesions were at other sites (odds ratio, 2.55; 95% confidence interval, 1.21 to 5.39). Stage per se, independent of lesion site, was not correlated with frequency and severity of dysmenorrhea and nonmenstrual pain. The severity of deep dyspareunia was related inversely to the endometriosis score (Spearman correlation coefficients for linear analog and verbal rating scales, respectively, -0.22 and -0.20). Kendall test by ranks revealed a correlation between linear analog and multidimensional pain scales in the rating of both dysmenorrhea and nonmenstrual pain (respectively, tau-b, 0.59 and tau-b, 0.68).
Endometriosis stage in the current classification was not related consistently to pain symptoms. The presence of vaginal lesions was associated frequently with severe deep dyspareunia. Dysmenorrhea and nonmenstrual pelvic pain were assessed with equal accuracy by a linear analog and a multidimensional scale.
To estimate the empirical relationship between the revised American Society for Reproductive Medicine's classification of endometriosis and pregnancy rates after treatment.
Retrospective analysis.
Patients seen by four practicing physicians.
Medical and/or surgical therapy for endometriosis.
Pregnancy defined as ongoing or delivered.
There were no significant differences in pregnancy rates across stages of endometriosis. There was a slight decline in pregnancy rates among patients with Stage IV endometriosis, but statistical significance was not achieved.
The use of an arbitrary weighted system for assigning scores to individual categories of disease, or for computing a total score, has limited the overall effectiveness of the classification system to predict pregnancy.
The purpose of this study was to assess the operating time of the most common gynaecological laparoscopic procedures. We analysed retrospectively 1000 consecutive operative laparoscopies on a procedure-by-procedure basis. Diagnostic laparoscopy and laparoscopic sterilization were specifically excluded from the analysis. The various laparoscopic procedures were grouped and analysed under six major categories. The average operating time for all cases was 76.9 min (range 10-400). In 38 cases (3.8%) the laparoscopic procedure was converted to laparotomy. The average operating time for treating ectopic pregnancy and tubal disease was approximately 60 min (range 13-240). Surgery for endometriosis and ovarian cysts averaged 72 min (range 10-240). Laparoscopic myomectomy and hysterectomy averaged 113 and 131 min respectively (range 25-400). Our results show that while the operating time for most operative laparoscopies is less than 75 min, the range of operating times is great. The relative lack of predictability in procedure times means that the efficient utilization of fixed theatre sessions is difficult.
The optimum method for the treatment of endometriosis remains unclear. This review explores recent data concerning the effectiveness of laparoscopic excision and associated therapies, to guide clinicians in their selection of the most appropriate therapeutic regimen.
Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. Adjuvant therapies such as the levonorgestrel intrauterine system and pre-sacral neurectomy may further improve outcomes. Ovarian endometrioma are invaginations of the uterine cortex, and surgical stripping of this cortex removes many primordial follicles. Despite this apparent disadvantage, stripping of the capsule is associated with better subsequent pregnancy rates and lower recurrence rates than the more conservative approach of thermal ablation to the superficial cortex.
Laparoscopic excision is currently the 'gold standard' approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies.
To examine the effect on pain and quality of life for women with all stages of endometriosis undergoing laparoscopic surgery compared with placebo surgery.
A randomized, blinded, crossover study.
A tertiary referral unit in a district general hospital.
Thirty-nine women with histologically proven endometriosis completed the 12-month study.
Women were randomized to receive initially either a diagnostic procedure (the delayed surgical group) or full excisional surgery (the immediate surgery group). After 6 months, repeat laparoscopy was performed, with removal of any pathology present.
The end points were changes from baseline values of visual analogue pain scores, validated quality-of-life instruments (EQ-5D and SF-12), and sexual activity questionnaire scores. Patients and assessors of outcomes were blinded to the treatment-group assignment.
Significantly more of the 39 women operated on according to protocol reported symptomatic improvement after excisional surgery than after placebo: 16 of 20 (80%) vs. 6 of 19 (32%); chi(2)(1) = 9.3. Other aspects of quality of life were also significantly improved 6 months after excisional surgery but not after placebo. Progression of disease at second surgery was demonstrated for women having only an initial diagnostic procedure in 45% of cases, with disease remaining static in 33% and improving in 22% of cases. Nonresponsiveness to surgery was reported in 20% of cases.
Laparoscopic excision of endometriosis is more effective than placebo at reducing pain and improving quality of life. Surgery is associated with a 30% placebo response rate that is not dependent on severity of disease. Approximately 20% of women do not report an improvement after surgery for endometriosis.
The role of laparoscopy in the diagnosis and medical treatment of endometriosis is changing. Diagnosis based on laparoscopic visualization of endometriotic implants alone is unreliable. However, clinical diagnosis based on noninvasive techniques such as history, symptoms and physical examination is correct in 78-87% of cases. The current approach to treatment of chronic pelvic pain in Italy involves first-line treatment with oral contraceptives or nonsteroidal antiinflammatory drugs. Second-line treatment involves gonadotropin-releasing hormone (GnRH) agonists administered with or without add-back therapy. Current guidelines suggest that in the absence of adnexal masses, estrogen-progesterone combinations can be administered without the need for preliminary laparoscopy.
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