{"paper_id":"1f7b3301-8170-4600-a5a5-8d9034cb447d","body_text":"Open Access, Volume 2 \nCorrelation between surgical findings and magnetic resonance \nimaging of deep infiltrating endometriosis\nReview Article\nwww.jcimcr.org\nJournal of\nClinical Images and Medical Case Reports\nReceived: Mar 16, 2021\nAccepted: Apr 23, 2021\nPublished: Apr 27, 2021\nArchived: www.jcimcr.org\nCopyright: © Roufael J (2021).\n*Corresponding Author: Jad Roufael\nObstetrics and Gynecology Department, Versailles \nHospital Center, 177 rue de Versailles, 78150 Le \nChesnay, France. \nEmail: jad.roufael@gmail.com\nISSN 2766-7820\nIntroduction\nEndometriosis is a multifocal gynecologic disease that affects \nwomen of reproductive age and may cause chronic pelvic pain \nand infertility. Deep infiltrating endometriosis is defined as a \nsub-peritoneal lesion more than 5mm deep. It can affect the \nparametrium, uterosacral ligaments, rectovaginal septum, rec -\ntum, vagina or the bladder [1,2]. Menstrual reflux has a major \nrole in the pathophysiology of endometriosis, and this explains \nthe predominance of the lesions in the posterior compartment \nof the pelvis and its asymmetric distribution.\nOther physio-pathological theories have been proposed such \nas the theory of vascular and lymphatic emboli and the theory \nof Mullerian metaplasia [3,4]. Recent studies suggest that DIE \nJad Roufael; Benjamin Fedida; Carmen Chis; Anais Guillermin; Penelope Labauge; Pierre Panel\nObstetrics and Gynecology Department, Versailles Hospital Center, 177 rue de Versailles, 78150 Le Chesnay, France.\nrepresents a unique entity of extrauterine endometriosis with \nenhanced pro-proliferative and angiogenetic characteristics [5]. \nIt can be responsible of a variety of symptoms like dysmenor -\nrhea, chronic or cyclic pelvic pain, dyspareunia, dysuria and \ndyschezia. One of its major complication is infertility. Treatment \noptions include In-Vitro Fertilization (IVF), surgery, or a combi -\nnation of both. The treatment of choice in case of endometrio-\nsis associated with infertility is currently investigated in multiple \ntrials. MRI is definitely an important tool for the diagnosis of \nendometriosis, but all begins with a careful clinical exam and \na transvaginal ultrasound which is the first imaging modality. \nThe final diagnosis is obtained after surgery by histopathology \nof the lesion. In this article we will show you the correlation \nAbstract\n In this review, images during surgical excision of Deep Infil -\ntrating Endometriosis (DIE) were correlated to preoperative Magnetic \nResonance Imaging (MRI) findings. MRI is known to be the best tool \nfor mapping DIE, it displays a high accuracy in the diagnosis and the \ncharacterization of endometriosis lesions. Recent studies showed \nalso that MRI findings can be correlated to the length of operating \ntime, to the duration of hospital stay, and to the risk of voiding prob-\nlems. In this article we emphasize on the importance of having an ex-\nperienced radiologist that has the ability of detecting adhesions and \nsuperficial peritoneal lesions, a value that was underestimated in pre-\nvious studies. DIE presents on MRI as an intermediate signal intensity \non T1-weighted images, hypointense signal on T2-weighted images, \nand homo- or heterogeneous enhancement after intravenous gado -\nlinium injection. Preoperative MRI findings help doctors to elaborate \na tailored therapeutic plan for each patient depending on the clinical \ncontext (Fertility preservation, IVF, complete surgical excisions). Most \nimportantly correct investigation and accurate description of small le-\nsions enhance surgical planification and adequate information of the \npatients.\nKeywords: Deep infiltrating endometriosis; Endometriosis; Laparo -\nscopic findings; Magnetic resonance imaging.\n\nwww.jcimcr.org                Page 2\nCitation: Roufael J, Fedida B, Chis C, Guillermin A, Labauge P , Panel P . Correlation between surgical findings and magnetic \nresonance imaging of deep infiltrating endometriosis. J Clin Images Med Case Rep. 2021; 2(2): 1076.\nbetween MRI and per operative findings [6,7,8]. It is to be noted \nthat all  images  were  analyzed  prospectively  by  a  specialized  \nradiologist.\nMagnetic resonance imaging protocol\nAll patients known or suspected to have endometriosis un -\ndergo pelvic MR imaging after injection of water in the rectum \nand sterile gel in the vagina. This technique allows a better visu-\nalization of the entire rectal and vaginal interface with the uter-\nus (to be noted that no injection was done for this patient to \nrespect patient’s preferences). Patients undergo the following \nprotocol: Axial, sagittal and coronal high resolution T2-weighted \nsequences. Axial and sagittal T1-weighted sequences with and \nwithout fat suppression.\nDIE can affect the uterosacral ligaments, rectovaginal sep -\ntum, the vagina, urinary tract, alimentary tract, diaphragm and \nother extraperitoneal sites. Accurate preoperative localisation \nof the disease is required for planning complete surgical exci -\nsion. The major two signs of deep infiltrating endometriosis on \nmagnetic resonance imaging are signal intensity abnormalities \nand morphologic changes. Fibrosis and adhesions often result in \nmorphologic changes, such as, nodular thickening of uterosac -\nral ligaments, intermediate or high signal intensity of DIE lesions \non T1-weighted images and hypointense lesions on T2-weight -\ned images. Mild to moderate enhancement may be observed \nafter gadolinium injection. The high sensitivity and specificity \nof MR Imaging was already discussed in the literature [9,10]. In \naddition, MR imaging can guide treatment decisions by showing \nthe extension of the disease and all the organs that are involved \nin the abdomen (ureters, appendix, diaphragm).\nCase presentation\nA 33-year-old patient, with no medical or surgical history \npresents to our clinic for primary infertility, dysmenorrhea, dys-\nuria, pollakiuria and deep positional dyspareunia. Patient was \nasymptomatic when she was on OCPs, however OCPs were \nstopped two years ago for the interest in becoming pregnant. \nBasic workup for organic causes of infertility was negative for \nher and her partner. However, given her symptoms, endome -\ntriosis was suspected, and clinical examination was pertinent \nfor left and right uterosacral ligament retraction.\nMagnetic resonance imaging showed\nFigure 1: Left uterosacral and left round ligament infiltration \n(nodular thickening) on sagittal T2-weighted images (A). Right \nand left uterosacral ligaments thickening on transverse T2-\nweighted images (B,C).\nFigure 2: Right and left nodular hyper intensity representing \nendometriosis implants in the right and left ovarian fossa on \ntransverse T1-weighted images (A,B). We identified also a 7mm \nright ovarian endometrioma (nodular hyper intensity on trans -\nverse T1-weighted images (nodular hyper intensity inside the \nlimits of the ovary) (B).\nFigure 3: Superficial endometriosis lesions of the “Douglas \nPouch” on transverse T2-weighted image.\nFigure 4: Endometriosis infiltration of the left round ligament \nrepresented by a nodular hyper intense lesion on transverse T1-\nweighted image (A), nodular hypo intense lesion on transverse \nT2-weighted image (B). Infiltration and thickening of the right \nround ligament on transverse T2-weighted image (B). Endome-\ntriosis infiltration of the uterovesical fold with retraction, fibro-\nsis and hemorrhagic peritoneal spots on transverse T1 and T2-\nweighted images (C,D).\nAll endometriosis lesions seen on MRI were identified dur -\ning surgery. We performed a complete laparoscopic resection \nof all endometriosis lesions; no complication was noted during \nor after the surgery. Patient was evaluated two months after \nsurgery; she noted the complete resolution of her symptoms, \nno dyspareunia, pollakiuria or dysuria.\nSurgical procedure\nThe installation features included a uterine manipulator, a \n12 mm trans- umbilical trocar for camera, two 5 mm trocars \n(in right and left iliac fossa) and another one in the hypogastric \nregion. Multiple endometriosis lesions were identified after a \ncareful examination of the peritoneal cavity.\nPosteriorly, endometriosis was found to be infiltrating\n- Douglas pouch: white “Stellar” lesions and peritoneal re -\ntraction (Figure 3: A).\n- Torus: reddish, “powder-burn” lesions and peritoneal re-\ntraction (Figure 1: E).\n- Right and left ovarian fossa: red and white “Stellar” le -\nsions, peritoneal retraction and increased vascularisation \n(Figure 2: C,E).\n- Uterosacral ligaments: dark black lesions, fibrosis and re-\ntraction causing deep positional dyspareunia (Figure 2: C, \nE).\nAt the level of the anterior compartment, we found endome-\ntriosis infiltration of:\n- Left and right round ligaments: large hemorrhagic lesions \npredominating on the right side, yellowish spots, retrac -\ntion and fibrosis (Figure 4: E).\n- Uterovesical fold: Yellowish, dark and smaller red spots, \nplus retraction and fibrosis of the peritoneal fold (Figure \n4: E).\nTo be noted that all these lesions were identified on MR \nimaging preoperatively as we showed before. After mobiliza -\ntion of the sigmoid and identification of the landmarks on the \npelvic wall, which are the nerves, ureter, and pelvic vessels, we \ndid a bilateral ureterolysis and resection of the right and left  \novarian fossa (Figure 2: D,F). Then a bilateral uterosacral liga -\nment resection was done sparing the hypogastric nerves on \nboth sides (Figure 1: F). A complete resection of the Douglas \npouch was achieved after opening the para rectal spaces, medi-\nally from the uterosacral ligaments, in order to avoid injury to \nthe hypogastric nerves (Figure 3: C). After that, we opened the \nvesico-vaginal space and we performed a complete resection of \nthe utero-vesical peritoneal fold (Figure 4: F). To be noted that \nthe use of uterine manipulator helps identifying different pelvic \nstructures and decreases surgical complications.\n\nwww.jcimcr.org                Page 3\nFigure 3: (A) Transverse T2-weighted image shows peripheral en -\ndometriosis lesions of the “Douglas Pouch”. (B), Circle shows the \nperitoneal infiltration of the Douglas pouch. The arrows specify the \nexact location of endometriosis lesions. (C) Shows the aspect af -\nter a complete posterior resection of endometriosis lesions shown \nbefore. Green lines show inferior hypogastric nerves. Yellow line \nshows the right ureter after ureterolysis. \nFigure 4:  (A) Transverse T1-weighted image, (B) Transverse T2-\nweighted image, circle shows endometriosis infiltration of the left  \nround ligament. (C) Transverse T2-weighted image, (D) Transverse \nT1-weighted image, circle shows endometriosis infiltration of the \nuterovesical fold with retraction, fibrosis and haemorrhagic peri -\ntoneal spots. Surgical findings (E), endometriosis infiltration of the \nuterovesical fold with haemorrhagic peritoneal spots. (F) Shows \ncomplete anterior resection of endometriosis lesions, arrows show \nleft and right round ligaments.\nFigure 1:  (A) Sagittal T2-weighted image shows left uterosacral \nand left round ligament infiltration. (B,C) Transverse T2- weighted \nimages show right and left uterosacral ligaments. (D) Transverse \nT1 weighted image shows hyper intense nodular implant. Surgical \nfindings (E), arrows show infiltration of “Utero sacral ligaments”. \nRectangle shows Infiltration of the” TORUS”. Circles show infiltra -\ntion and retraction of the right ovarian fossa. (F) Green lines show \ninferior hypogastric nerves after dissection and resection of DIE. \nYellow line shows the right ureter after ureterolysis.\nFigure 2: (A,B) Transverse T1-weighted image shows right and left  \nnodular hyper intensity representing endometriosis implants. (C,E) \nArrows show infiltration of “Uterosacral ligaments”. Rectangle \nshows Infiltration of the” TORUS”. Circle shows infiltration and re-\ntraction of the right ovarian fossa. (D,F) Green lines show inferior \nhypogastric nerves after dissection and resection of DIE. Yellow \nlines show right and left ureters after ureterolysis.\n\n\nwww.jcimcr.org                Page 4\nDiscussion\nEndometriosis may be difficult to identify on MR imaging es-\npecially for mild and superficial lesions. As we can see in “Figure \n1, 3” the infiltration of the “Douglas pouch and the uterosacral \nligaments” is subtle especially in the absence of clear morpho -\nlogic changes. In our department of Obstetrics and gynecology \nwe systematically conduct multidisciplinary meetings to corre -\nlate preoperative and postoperative findings. This allows clinical \ndiscussion of the medical case and helps gynecologists and ra -\ndiologists in improving their skills to offer the best patient care. \nIn this case all endometrial lesions found during surgery were \nalready described and mapped by our experienced radiologist. \nMR imaging is useful in guiding and planning surgical treatment \nfor the disease. Having an exact mapping of the lesions allows \nsurgeons to be better prepared for the surgical act especially \nwhen multiple surgical specialties are involved (ex: colostomy, \nureteral stenting). It allows also patients to be better informed \nregarding their length of hospital stay, clinical outcome. etc.\nConclusion\nCorrelation between surgical findings and magnetic reso -\nnance imaging of deep infiltrating endometriosis may have \na positive impact on the treatment of patients suffering from \nendometriosis. In this article we want to focus also on the im -\nportance of referring patients to surgeons who are frequently \ndealing with endometriosis like in our referral centre at “Ver -\nsailles Hospital Centre” as this will increase the chances of hav-\ning a complete endometriosis resection and a better clinical \noutcome. Most importantly correct investigation and accurate \ndescription of small lesions enhance surgical planification and \nadequate information of the patients.\nReferences\n1. Koninckx PR, Ph D, Suggestive evidence that pelvic endometrio-\nsis is a progressive disease, whereas deeply infiltrating endome-\ntriosis is associated with pelvic pain. Fertil. Steril. 1991; 55: 759-\n765.\n2. Luciano DE, Luciano AA. Management of endometriosis-related \npain: An update. 2011; 7: 585-590.\n3. Borghese B, Santulli P , Marcellin L, Chapron C. 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