Gynaecology • Gynécologie
Prevalence of Deep Endometriosis and Rectouterine Pouch Obliteration in the Presence of Normal Ovaries

https://doi.org/10.1016/j.jogc.2020.04.007Get rights and content

Abstract

Objective

It is well-established that there is a strong association between ovarian endometriomas (OE) and deep endometriosis (DE) and rectouterine pouch (RP) obliteration. We aimed to determine the prevalence of DE and RP obliteration in the presence of normal ovaries.

Methods

We conducted a multicentre retrospective cohort study from January 2009 to December 2017 using a prospective multicentre data registry. Participants included patients with signs and/or symptoms of endometriosis who underwent excisional laparoscopic surgery at one of eight hospitals. The primary outcome was the prevalence of DE and RP obliteration, which was compared between women with normal ovaries (i.e., no OE) and women with ovaries containing OE. Secondary outcomes evaluated included rates of DE by anatomic site between women with and without OE.

Results

The ovaries did not contain an OE in 319 of 410 patients (77.8%). The prevalence of DE and RP obliteration in this cohort was 25.4% and 9.7% (81 and 31 patients), respectively; whereas, in patients with OE, DE and RP obliteration prevalence was 68.1% and 60.4% (62 and 55 patients), respectively (P < 0.001 for both DE and RP obliteration). The uterosacral ligaments were the most common site for DE (right: 47/319 [14.7%]; left: 42/319 [13.2%]).

Conclusions

In patients who visited a tertiary care centre with endometriosis without ovarian involvement, 1 in 4 had DE and 1 in 10 had RP obliteration. These prevalence rates should encourage knowledge and skills dissemination to improve non-invasive imaging diagnosis overall. In patients with symptoms or signs suggestive of endometriosis, a basic pelvic ultrasound that ends at evaluation for OE should not be regarded as reassuring.

Résumé

Objectif

Il est reconnu qu'il existe une forte association entre l'endométriome ovarien et l'endométriose profonde et l'oblitération du cul-de-sac de Douglas. Nous cherchions à déterminer la prévalence de l'endométriose profonde et de l'oblitération du cul-de-sac de Douglas en présence d'ovaires normaux.

Méthodologie

Nous avons mené une étude de cohorte rétrospective multicentrique de janvier 2009 à décembre 2017 au moyen d'un registre prospectif multicentrique de données cliniques. Les participantes se composaient de patientes ayant des signes ou symptômes d'endométriose qui ont subi une exérèse laparoscopique dans l'un des huit hôpitaux de l’étude. Le critère de jugement principal était la prévalence de l'endométriose profonde et de l'oblitération du cul-de-sac de Douglas calculée par comparaison entre les femmes ayant des ovaires sains (c.-à-d. sans endométriome ovarien) et celles atteintes d'endométriomes ovariens. Les critères secondaires évaluaient le taux d'endométriose profonde d'après le siège de l'endométriose entre les femmes atteintes ou non d'endométriomes ovariens.

Résultats

Aucun endométriome ovarien n'a été observé chez 319 des 410 patientes (77,8 %). La prévalence de l'endométriose profonde et de l'oblitération du cul-de-sac de Douglas dans cette cohorte était respectivement de 25,4 % et de 9,7 % (81 et 31 patientes); chez les patientes présentant des endométriomes ovariens, une endométriose profonde et une oblitération du cul-de-sac de Douglas, la prévalence était quant à elle de 68,1 % et 60,4 % (62 et 55 patientes) respectivement (P < 0,001 pour l'endométriose profonde et l'oblitération du cul-de-sac de Douglas). Les ligaments utéro-sacrés constituaient le plus fréquent des sièges de l'endométriose profonde (droit : 47/319 [14,7 %]; gauche : 42/319 (13,2 %).

Conclusions

Chez les patientes atteintes d'endométriose sans atteinte ovarienne qui ont visité un centre de soins tertiaires, 1 sur 4 présentait une endométriose profonde et 1 sur 10 présentait une oblitération du cul-de-sac de Douglas. Ces taux de prévalence indiquent qu'il y a lieu de favoriser la transmission des connaissances et l'amélioration des compétences afin d'améliorer globalement le diagnostic par les méthodes d'imagerie non invasives. Chez les patientes manifestant des signes ou symptômes caractéristiques de l'endométriose, une échographie pelvienne de base se concluant par la recherche d'endométriomes ovariens ne devrait pas être considérée comme rassurante.

Section snippets

INTRODUCTION

Patients with symptoms and signs of endometriosis are often investigated with transvaginal ultrasound (TVS) as a first-line imaging tool.1 As per the Society of Obstetricians and Gynaecologists of Canada and the Canadian Association of Radiologists, basic TVS includes assessment of the uterus and adnexa and a limited view of the rectouterine pouch (RP) for fluid.2 The American Institute of Ultrasound in Medicine description is similarly limited.3 Of the three phenotypes of endometriosis, only

Design

This was a multicenter, retrospective cohort study using a prospectively collected registry (Excel 2007; Microsoft Corp., Redmond, WA) of clinical data (January 2009 to December 2017). Data from earlier editions of this database have been previously analyzed and published.17,26,27

Setting

Patients underwent clinical consultation or expert-guided TVS at one of two tertiary referral gynaecological centres: OMNI Gynaecological Ultrasound and Care in Sydney, Australia, or the Acute Gynaecology, Early

Participants

The 411 patients who underwent clinical assessment, expert-guided TVS, and laparoscopic surgery for endometriosis were confirmed as eligible for this study. All patients had at least one ovary, with 6 and 1 having undergone a left and right oophorectomy, respectively. One patient was missing surgical ovarian data and was excluded from analysis. The Figure depicts a flow diagram of study participants, including the prevalence of OE in each unique ovarian group. Table 1 summarizes the demographic

DISCUSSION

We have demonstrated that DE and RP obliteration are present in one in four and one in 10 patients without an OE, respectively. The most common site of DE in these patients was the USL (Table 2). The rates of DE in the presence of OE that we report here are consistent with previous literature.5,7,8,30 Although not the main emphasis of our study, we confirm the strong association between OE and DE/RP obliteration, which is aligned with previous literature.5, 6, 7 This study should act as a

Acknowledgements

The authors would like to thank Dr. Ishwari Casikar, Dr. Fernando Infante, Dr. Uche Menakaya, Dr. Bassem Gerges, and Dr. Batool Nadim for their contribution to the data collection. They also thank the following laparoscopic surgeons for their contribution to this study: Dr. Dheya Al-Mashat, Dr. Greg Cario, Dr. Danny Chou, Associate Professor Michael Cooper, Dr. Qemer Khoshnow, Dr. David Kowalski, and Dr. Geoffrey Reid.

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    • Cited by (0)

    Disclosures: The authors declare they have nothing to disclose.

    All authors have indicated that they meet the journal's requirements for authorship.

    This study was presented at (1) the 29th World Congress of Ultrasound in Obstetrics and Gynecology, Berlin, Germany, October 13–16, 2019; and (2) the 48th AAGL Global Congress on Minimally Invasive Gynecology, Vancouver, BC, November 11–13, 2019

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