Diagnosis of endometriosis of the rectovaginal septum using introital three dimensional ultrasonography

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Diagnosis of endometriosis of the rectovaginal septum
using introital three-dimensi
Maria Angela Pascual, M.D., Ph.D.,a Stefano Guerriero, M
Pedro Barri-Soldevila, M.D.,a Silvia Ajossa, M.D.,b Betlem
a Department of Obstetrics, Gynecology, and Reproduction, Insti
Spain; b Department of Obstetrics and Gynecology, University o
Universitari Dexeus, University of Barcelona, Barcelona, Spain
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implants penetrating the retroperitoneal space for a dis-
5 mm or more. This disease involves several locations
the rectovaginal septum (1) but seems difficult to assess
al examination only (2, 3). Preoperative evaluation is
y for the selection of different medical or surgical
nd for the selection of an appropriate surgeon with
experience in this kind of surgery (4).
aginal ultrasonography (US) should be considered the
rocedure (5), but this technique seems to have controver-
s in the diagnosis of deep endometriosis in some of the lo-
s a matter of fact, some authors have reported a sensitivity
the rectovaginal septum location (6) although more en-
results have been obtained by other authors using modi-
iques (3, 7–9).
ast few years, the lower part of the pelvis has been studied
necologists using three-dimensional (3D) introital US
but until now no studies have evaluated the role of this
nique in the identification of deep endometriosis of the
nal septum. The aim of this study was to evaluate the
rectovaginal septum endometriosis.
MATERIALS AND METHODS
This prospective study involved a series of 39 consecutive
with clinically suspected endometriosis on the basis o
history of pelvic pain and/or clinical examination and un
surgery at the Department of Obstetrics, Gynecology, an
duction at the Instituto Universitario Dexeus of Barcelo
January 2008 through July 2009. Diagnosis of rectovaginal
triosis was proved histologically for each patient. This obse
study protocol was approved by our Institutional Review B
All patients first underwent a two-dimensional (2D)
transvaginal US examination with use of a standard US
(Aplio-50 SSA-700; ToshibaMedical Systems, Tokyo, Japa
noline Antares; SiemensMedical Systems Inc., Erlangen, G
equipped with a vaginal multifrequency probe. After scan
uterus and adnexal regions, attention was paid to the ovarie
of Douglas, vesicouterine pouch, and uterosacral ligament.
ginal US scans were carried out by three experienced e
(M.A.P., L.H., B.G.).
All participating patients then were informed that an a
3D-US examination would be performed to obtain further
tion regarding the rectovaginal septum. Images were obtai
the Voluson 730 Expert and E8 (GE Healthcare, Milwauk
fitted with a transvaginal multifrequency (2.9–10 and 3.2–
respectively) transducer.
January 11, 2010; revised February 22, 2010; accepted
y 23, 2010; published online March 31, 2010.
s nothing to disclose. S.G. has nothing to disclose. L.H. has
to disclose. P.B.-S. has nothing to disclose. S.A. has nothing
se. B.G. has nothing to disclose. I.R. has nothing to disclose.
uests: Stefano Guerriero, M.D., Department of Obstetrics and
logy of the University of Cagliari, Ospedale San Giovanni di Dio,
edale 46, 09124, Cagliari, Italy (FAX: 39-070-668575; E-mail:
guerriero@tiscali.it).
2/$36.00 Fertility and Sterility� Vol. 94, No. 7, December 2010
Objective: To evaluate the diagnostic accuracy of intro
preoperative detection of rectovaginal septal endometri
Design: Ultrasonographic results were compared with
Setting: University Department of Obstetrics and Gyne
Patient(s): This prospective study included 39 women
Intervention(s): All patients underwent 3D transvaginal
before undergoing laparoscopic radical resection of en
hypoechoic areas, nodules, or anatomic distortion of th
Main Outcome Measure(s): Sensitivity, specificity, an
with 95% confidence intervals (CIs).
Result(s): Surgery associated with histopathologic evalu
tum in 19 patients. The specificity, sensitivity, positive l
(95% CI, 78.6%–99.7%), 89.5% (95%CI, 73.3%–94.5%
respectively.
Conclusion(s): Introital 3D ultrasonography seems to be
the rectovaginal septum and should be included in the pr
deep endometriosis. (Fertil Steril� 2010;94:2761–5. �2
Key Words: Three-dimensional ultrasonography, rectov
16/j.fertnstert.2010.02.050 Copyright ª2010 American S
nal endometriosis, diagnosis
onal ultrasonography
.D.,b Lourdes Hereter, M.D.,a
Graupera, M.D.,a and Ignacio Rodriguez, B.Sc.c
tut Universitari Dexeus, University of Barcelona, Barcelona,
f Cagliari, Cagliari, Italy; and c Unit of Biostatistics, Institut
l three-dimensional (3D) transvaginal sonography for
.
ical and histologic findings.
ogy.
h suspected rectovaginal endometriosis.
ography for the evaluation of the rectovaginal septum,
etriosis. Rectovaginal endometriosis was defined as
ecific location.
kelihood ratios (positive or negative) were calculated
on revealed deep endometriosis in the rectovaginal sep-
lihood ratio, and negative likelihood ratio were 94.7%
7.2 (95%CI, 2.51–115), and 0.11 (95% CI, 0.03–0.41),
effective method for the diagnosis of endometriosis of
2761
ociety for Reproductive Medicine, Published by Elsevier Inc.
FIGURE 1 FIGURE 2
(A) The drawing shows the anatomic structures visualized by 3D
transperineal US in a sagittal plane (symphysis pubis, urethra,
neck bladder, vagina, and rectum). Themultiplanar reconstruction
of the sagittal acquisition allows visualization of rectovaginal
septum (oval area). (B) Sagittal plane of pelvic floor as visualized by
3D transperineal US (oval area). R ¼ rectum; V ¼ vagina; B ¼
bladder; U ¼ urethra; S ¼ symphysis pubis.
Pascual. Techniques and instrumentation. Fertil Steril 2010.
Introital 3D-US examinations were performed with the trans-
ducer placed on the perineum. The transducer was placed quite
firmly against the symphysis pubis without causing significant dis-
comfort. To acquire a correct volume, the symphysis pubis, urethra,
vagina, and rectum should be visualized in the same image (Fig. 1A
and B). Gain is adjusted and focal area is set to the region of interest
with the sweep angle set at 90 degrees (Voluson 730 Expert) or 120
degrees (Voluson E8). Volume acquisition lasted <1 minute. This
produced a multiplanar image showing the symphysis pubis, urethra
and bladder neck, vagina, and rectum in three planes: longitudinal,
transverse, and coronal (Fig. 1A and B).
When the volume acquisition was completed, the data file was
sent via Digital Imaging and Communication inMedicine (DICOM)
to a personal computer and stored to be analyzed with use of the ap-
propriate software (4Dview 5.0; GE Healthcare).
All 3D volumes were acquired by three different operators (L.H.,
B.G., M.A.P.) using the same scanning protocol. However, stored
3D volumes were analyzed by just one examiner (L.H.). When 3D
data were opened, images were displayed in three orthogonal planes
and reviewed by using multiplanar navigation and the render mode
available in the 4Dview version 5 (Fig. 2A and B). By 3D-US, deep
endometriosis implantswere suspected by the presence of hypoe-
choic areas, nodules, or anatomic distortion of this specific location
(Fig. 3) with use of render mode in the coronal plane obtained after
multiplanar navigation.
All patients underwent surgery within 1 month after 3D evalua-
tion. The surgical procedure is described in detail as follows. Lapa-
roscopic approach was made through the umbilicus with the use of
a Veress needle and an 11-mm trocar. Accessory trocars were placed
2762 Pascual et al. Techniques and instrumentation
(A) Schematic cross-section view of the female pelvic floor. The
area in the circle represents the rectovaginal septum as shown by
3D imaging. (B) Axial rendering volume of the pelvic floor. The
image shows the urethra, vagina, and rectum. The rectovaginal
septum is delimited by vagina and rectum. P¼ pubis; U¼ urethra;
V ¼ vagina; R ¼ rectum; OE ¼ obturator externus; OI ¼ obturator
internus; LA ¼ levator ani.
under visual control in the left iliac fossa (5 mm), midline between
umbilicus and pubis (5 mm), right iliac fossa (12 mm), and right
paraumbilical (5 mm). The key to this type of surgery is to work
from healthy to damaged tissue. This centripetal approach allows
the surgeon to identify pelvic organs and separate them from endo-
metriotic tissue. All endometriotic foci are removed. The proce-
dure was started by the eventual adnexal adhesiolysis and
temporary suspension to the abdominal wall with a 2/0 silk suture.
In case parametrial endometriosis is present, a full broad ligament
opening and eventual uterine artery ligation might be needed to re-
move the damaged tissue. Bilateral opening of the pararectal fossa
was performed until the affected area was achieved. A rectal and
vaginal probe was placed to expose the rectovaginal septum. Cau-
tious dissection was made until the rectum was divided fully from
the vagina. Depending on the possible rectal infiltration, the node
was left attached to the vagina or the rectum. In case of posterior
vaginal fornix infiltration, a partial colpectomy and suture need to
be performed.
In case the rectal infiltration exceeded 2 cm in diameter, or clear
signs of rectal constriction were detected, rectal resection was ad-
vised. The rectum was sectioned in healthy tissue with one or two
Pascual. Techniques and instrumentation. Fertil Steril 2010.
Vol. 94, No. 7, December 2010
FIGURE 3
of t
Three-dimensional multiplanar reconstruction with the render mode
rectovaginal septum, between the rectum and vagina (arrows).
loads of mono-use stapler. A 3- to 5-cm minilaparotomy was per-
formed, and the rectal stump was exposed and sectioned. The rectal
probe of the endoanal stapler was then placed, the rectum reinserted
in the abdominal cavity, and the laparotomy closed. Rectal anasto-
mosis was made with the endoanal stapler under laparoscopic con-
trol. If the conservative option of the rectum was decided on, local
full resection of the node was performed. In case the bowel lumen
was opened, a transversal suture with 3/0 Vicryl (Ethicon, Sommer-
ville, NJ) suture was performed. In both cases, rectal integrity was
checked by filling the pelvis with saline solution and anal injection
of air. If a leakage was detected, reinforcement of the suture was
mandatory, and, if optimal suturing was not achieved, a temporary
ileostomy was advised. Staging of the disease and scores were
performed with use of the American Fertility Society (AFS)
classification (13).
The findings at 3D-US were compared with the findings at sur-
gery with histopathologic confirmation of presence of endometri-
osis. Sensitivity, specificity, and likelihood ratios (LRþ or LR-)
were calculated with 95% confidence intervals (CIs), according to
the Statement for Reporting Diagnostic Accuracy Studies (STARD)
Pascual. Techniques and instrumentation. Fertil Steril 2010.
Fertility and Sterility�
he coronal plane shows an endometriotic nodule on the left of the
(14). The calculation of sample size is not mandatory in a diagnostic
study on the basis of STARD guidelines. Likelihood ratios were
used because they are not affected by the prevalence of disease in
the population studied (14).
RESULTS
We included 39 women in the study. The mean age (�SD) of the
study population was 35.6� 5.7 years, ranging from 25 to 44 years.
The indication for surgery was clinically suspected endometriosis on
the basis of patient clinical examination associated with pelvic pain
in all 39 patients, of whom 15 patients had associated infertility. All
patients reported the presence of dyspareunia and/or dysmenorrhea.
All 39 had previous treatment for persistent pelvic pain with medica-
tions estroprogestins and/or GnRH agonist and nonsteroidal anti-
inflammatory drugs for at least 1 year. In 38 patients out of 39 the
volume acquisition by 3D-US allowed a good multiplanar analysis
of the rectovaginal septum; in only one case the volume quality
was not adequate to be reelaborated because of a poor visualization
of the rectum. This casewas not considered in the statistical analysis.
2763
Surgery associated with histopathologic evaluation revealed deep
endometriosis in the rectovaginal septum in 19 patients. In these
.38 � 36.43 (stage I:
s
ov
nt
g
s
h
in
n
e
p
re
t
In the diagnosis of deep endometriosis, as suggested by Guerriero
et al. (16), the first advantage can be very useful to correctly locate
the lesions in the pelvis evaluating the spatial relationship with other
ha
c
t
ne
o
g
l
e
a
t
th
t
osis (6). In our study we could not compare 2D introital images with
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0.52–0.94). Positive LR was 17.2 (95% CI, 2.51–115), and negative
LR was 0.11 (95% CI, 0.03–0.41), both indicating a good to excel-
lent test. The pretest probability of rectovaginal involvement of deep
pelvic endometriosis in our population was 50%, and this probabil-
ity of disease rose to 94% when the test was positive and decreased
to 10% when the test was negative.
DISCUSSION
Introital 3D-US seems to be an effective means of detecting endo-
metriosis of the rectovaginal septum and should be included in pre-
operative evaluation in patients with clinical suspicion of
rectovaginal endometriosis. To the best of our knowledge, this is
the first prospective study about introital 3D-US and deep endome-
triosis. As suggested by Downey et al. (15), 3D-US has at least three
advantages over 2D-US: [1] it seems to be highly reproducible, and
the image can be reconstructed after a single sweep of the ultrasound
beam across the target; [2] it may allow unrestricted access to an in-
finite number of viewing planes; and [3] stored 3D volumes can be
reassessed and compared by the same or different examiners over
time.
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2764
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Vol. 94, No. 7, December 2010
94.5%) associated with a very high kappa value of 0.84 (95% CI,
Using 3D-US we obtained a specificity of 94.7% (95% CI,
78.6%–99.7%) with a sensitivity of 89.5% (95% CI, 73.3%–
the pelvis usually impossible to evaluate with use of the simple
2D evaluation. For these reasons some studies report poor results
of 2D in the evaluation of this specific location of deep endometri-
patients the mean (�SD) AFS score was 40
5 patients, 12.8%; stage II: 4 patients, 10.3%;
43.6%; stage IV: 13 patients, 33.3%).
The 2D-US showed endometriosis of the
(97%) and the pouch of Douglas in 23 patie
guished endometriosis of the pouch of Dou
the posterior wall of the uterus and endometrio
septum as infiltration of the posterior wall of t
terior rectal wall (Fig. 2). In all the patients
2D-US completely missed the presence of e
in this specific location.
Of the 20 patients considered negative by
were confirmed as negative, and in 2 patients
rectovaginal septum was present. Of the 18
present deep endometriosis by 3D-US, 17 we
roscopy. In one patient with diagnosis of rec
osis, no pathologies were found at surgery.
tage III: 17 patients,
aries in 38 patients
s (59%). We distin-
las as infiltration of
is of the rectovaginal
e vagina and the an-
cluded in the study,
dometriotic nodules
3D introital US, 18
ndometriosis of the
atients suspected to
confirmed by lapa-
ovaginal endometri-
organs. The second c
the first acquisition to
the bowel. The third
the effect of medical
According to Rai
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displays of the ima
these images can be
a fascinating ‘‘virtua
of the lesion, a plan
2D-US.
As suggested by G
could allow a better
struction might make
With use of 3D-US
easily. In the presen
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Fertility and Sterility�
 2765
	Diagnosis of endometriosis of the rectovaginal septum using introital three-dimensional ultrasonography
	Materials and methods
	Results
	Discussion
	References