{"paper_id":"59f1004e-ce00-4338-9244-398edc7d0615","body_text":"Integrative Gynecology and Obstetrics Journal\nVolume 3 Issue 2\nResearch Open\nIntegr Gyn Obstet J, Volume 3(2): 1–2, 2020 \nIn 1860, a Viennese pathologist named Carl Rokitansky first \ndescribed histopathological features of adenomyosis by examination \nof histological sections of the uterus and the rectovaginal Space (RVS) \n[1]. First descriptions of radical surgical interventions reach back until \n1903 when the German gynecologist H. Füth published a noteworthy \ncase of a rectal shaving procedures including a radical hysterectomy \nprocedure performed for a patient with extensive rectovaginal DE on \nthe Lofot Islands, reporting on a “depressed vaginal vault and ulcerated \nsurface the size of a half-a-crown” as well as a “….fixed mass the size of \na fist stuck above the cervix just posterior to the uterus” [2].\nInterestingly, the main surgical principles of radical resection of \nrectovaginal DE are similar to those described by the pioneer surgeons \nof the early 20th century. However, significant advances in minimally \ninvasive surgical techniques have lead to the more widespread use of \nsurgical treatment since then and surgical morbidity and mortality \nare – obviously – by far lower then a century ago. Today the treatment \nof endometriosis remains the same as it was when first described: \nthe resection of all identified endometriotic lesions and preservation \nof reproductive function in patients wishing to conceive. However, \nbesides minimal invasive approaches, the use of antibiotics and the \narmory of high-tech medicine it is first and foremost surgical skill \nand knowledge about the extent of the disease which will decide on \noptimal or suboptimal outcomes of surgical interventions. The lack \nof information about the extent of the disease before and during \nthe procedure often leads to incomplete resections and pseudo-\nrecurrences. So how can knowledge on the extent of endometriosis, \nespecially DE be increased before embarking on surgery?\nThe most cost effective, easy-at-hand and highly accurate non-\ninvasive imaging method is  ransvaginal sonography (TVS), which \nis nowadays regarded as the first line diagnostic tool for patients with \nsuspected endometriosis. Within this, 2 issues should be discussed: the \naccuracy of TVS for detection of DE and the need and applicability of a \neasy to use classification system that serves surgeon and sonographers \nto guide surgical therapies and plan interdisciplinary procedures.\nSeveral meta-analysis have demonstrated that TVS accurately \ndetects DE affecting the rectosigmoid, urinary bladder and uterosacral \nOpinion Article \nHow does Transvaginal Sonography Influence \nSurgical Strategies in Deep Endometriosis - The Role \nof the Classification System ENZIAN\nGernot Hudelist\n1\n* and Joerg Keckstein\n2\n1\nDepartment of Gynaecology, Center for Endometriosis, Hospital St. John of God, Vienna, Austria\n2\nEndometriosis Centre - Dres. Keckstein Villach, Austria\n*Corresponding author:  Gernot Hudelist, MD, MSc, Hospital St. John of God, Johannes Gott Platz 1, 1020 Vienna, Austria\nReceived: September 01, 2020; Accepted: September 08, 2020; Published: September 15, 2020\nligaments (USL`s) in experienced hands with – for example -overall, \nlikelihood ratio pooled sensitivity, specificity, positive\nratio (LR+) and negative likelihood ratio (LR-) for detecting DIE in \nthe rectosigmoid up to 91% (95%CI, 85-94%), 97% (95%CI, 95-98%), \n33.0 (95%CI, 18.6-58.6) and 0.10 (95%CI, 0.06-0.16), respectively \n[3-5]. In addition, surgical risk factors such as low and deep rectal \nendometriosis, consequently low anastomotic height and therefore the \nelevated risk of anastomotic leakage (AL) following bowel resection \nmay be correctly predicted by TVS [6].\nSecondly, sonographers and surgeons need to speak the same \nlanguage when describing DE with the aim to adequately stage DE \npreoperatively and facilitate optimal interdisciplinary surgery. Some \nattempts have been made to correlate the most widely used rASRM \nscore with the results of TVS showing high accuracy for prediction of \nrASRM stages I-IV using TVS [7].\nHowever, the rASRM score primarily describes the extent of \nintra-abdominal, tubo-ovarian adhesions and is of limited value when \ndescribing the extent and localization of severe DE. Extraperitoneal \nlocalization of the foci and/or severe adhesions may also obscure \nanatomical spaces and DE, which will only be correctly staged when \nsurgery is expanded and hidden compartments and DE are exposed. \nAs a result, another staging system named the ENZIAN classification \nhas gained increasing acceptance by surgeons and diagnosticians since \nit is based on anatomical compartments and DE [8,9]. Recommended \nby several guidelines [10,11] there is now also evidence that – in \ncontrast to the rASRM score – DE described by the ENZIAN score \ndoes indeed significantly correlate with type and severity of symptoms \nin women with DE [12]. This knowledge opens up future new insights \ninto the disease, which were not possible with the application of the \nrASRM classification. Furthermore, there is increasing evidence \nthat the ENZIAN classification is also applicable to MRI and TVS \nunderlining its use in surgical staging and diagnostic workup with \nsurgical planning [13-17].\nSo how does TVS influence surgical therapy? The answer is \nsimple – by detailed knowledge on the true extent and localization of \nthe disease. Endometriosis surgery used to be determined primarily \nlikelihood\nt \n\nIntegr Gyn Obstet J, Volume 3(2): 2–2, 2020 \nGernot Hudelist (2020) How does Ttransvaginal Sonography Influence Surgical Strategies in Deep Endometriosis - The Role of the Classification \nSystem ENZIAN\nby decisions made during surgery. By using non-invasive tools such \nas TVS can now provide the surgeon with a detailed image of the \nlocalization and extent of DE, which is essential and makes complete \nand safe endometriosis surgery much easier.\nRoutinely performed and widespread use of non-invasive imaging \nwith TVS can, as a consequence and in the ideal scenario, lead to \ntriage of women with suspected endometriosis to a surgical “low-\nrisk” and “high risk” group. In the authors opinion, women with DE \nexhibiting colorectal, vaginal or ureteral involvement should – similar \nto oncological patients – be dealt as “high risk” patients and be treated \nby skilled and well-trained high-volume gynecological surgeons \nin tertiary referral centers with colorectal and urological surgeons \nin a team setting. This may increase optimal surgical outcomes and \nminimize severe complications [18]. TVS is the optimal tool to guide \nthis referral strategy. The additional use of a generally applicable \nclassification score such as the ENZIAN system has the potential to \nenable clinicians dealing with endometriosis to communicate with \none common language, independent on the diagnostic technique or \nsurgical treatment method. Bona diagnosis, bona curatio.\nReferences\n1. Rokitansky K (1860) Ueber Uterusdruesen-Neubildung. Zeitschrift der kaiserl königl \nGesellschaft der Aerzte zu Wien 37: 578-581.\n2. Hudelist G, Keckstein J, Wright JT (2009) The migrating adenomyoma: past views on \nthe etiology of adenomyosis and endometriosis. Fertil Steril 92: 1536-1543. [crossref]\n3. Hudelist G, English J, Thomas AE, Tinelli A, Singer CF , et al. (2011) Diagnostic \naccuracy of transvaginal ultrasound for non-invasive diagnosis of bowel \nendometriosis: systematic review and meta-analysis. Ultrasound Obstet Gynecol 37: \n257-263. [crossref]\n4. Guerriero S, Ajossa S, Orozco R, Perniciano M, Jurado M, et al. (2016) Accuracy \nof transvaginal ultrasound for diagnosis of deep endometriosis in the rectosigmoid: \nsystematic review and meta-analysis. Ultrasound Obstet Gynecol  47: 281-289. \n[crossref]\n5. Guerriero S, Ajossa S, Minguez JA, Jurado M, Mais V , et al. (2015) Accuracy \nof transvaginal ultrasound for diagnosis of deep endometriosis in uterosacral \nligaments, rectovaginal septum, vagina and bladder: systematic review and meta-\nanalysis. Ultrasound Obstet Gynecol 46: 534-545. [crossref]\n6. Aas-Eng MK, Dauser B, Lieng M, Condous G, Hudelist G (2020) Transvaginal \nsonography accurately predicts lesion to anal verge distance in women with deep \nendometriosis of the rectosigmoid. Ultrasound Obstet Gynecol.\n7. Leonardi M, Espada M, Choi S, Chou D, Chang T, et al. (2020) Transvaginal \nUltrasound Can Accurately Predict the American Society of Reproductive Medicine \nStage of Endometriosis Assigned at Laparoscopy. J Minim Invasive Gynecol  4650: \n30117-30125. [crossref]\n8. Tuttlies F , Keckstein J, Ulrich U, Possover M, Schweppe KW , et al. (2005) [ENZIAN-\nscore, a classification of deep infiltrating endometriosis]. Zentralbl Gynakol 127: 275-\n281. [crossref]\n9. Keckstein J, Ulrich U, Possover M, Schweppe KW (2003) ENZIAN-Klassifikation der \ntief infiltrierenden Endometriose. Zentralbl Gynäkol 125: 291.\n10. Ulrich U, Buchweitz O, Greb R, Keckstein J, von Leffern I, et al. (2013) \nInterdisciplinary S2k Guidelines for the Diagnosis and Treatment of Endometriosis. \nGeburtshilfe Frauenheilkd 73: 890-898.\n11. Working group of Esge E, Wes, Keckstein J, Becker CM, Canis M, et al. (2020) \nRecommendations for the surgical treatment of endometriosis. Part 2: deep \nendometriosis. Human Reproduction Open 2020: 002. [crossref]\n12. Montanari E, Dauser B, Keckstein J, Kirchner E, Nemeth Z, et al. (2019) Association \nbetween disease extent and pain symptoms in patients with deep infiltrating \nendometriosis. Reprod Biomed Online 39: 845-851. [crossref]\n13. Burla L, Scheiner D, Samartzis EP , Seidel S, Eberhard M, et al. (2019) The ENZIAN \nscore as a preoperative MRI-based classification instrument for deep infiltrating \nendometriosis. Arch Gynecol Obstet 300: 109-116. [crossref]\n14. Di Paola V , Manfredi R, Castelli F , Negrelli R, Mehrabi S, et al. (2015) Detection \nand localization of deep endometriosis by means of MRI and correlation with the \nENZIAN score. Eur J Radiol 84: 568-574. [crossref]\n15. Haas D, Chvatal R, Habelsberger A, Schimetta W , Wayand W , et al. (2013) \nPreoperative planning of surgery for deeply infiltrating endometriosis using the \nENZIAN classification. Eur J Obstet Gynecol Reprod Biol 166: 99-103. [crossref]\n16. Hudelist G, Montanari E, Dauser B, Nemeth Z, Keckstein J (2020) Comparison \nbetween sonography-based and surgical extent of deep endometriosis (DE) using \nthe Enzian classification, Abstract, Meeting of the Stiftung Endometrioseforschung, \nWeissensee.\n17. Thomassin-Naggara I, Lamrabet S, Crestani A, Bekhouche A, Wahab CA, et al. (2020) \nMagnetic resonance imaging classification of deep pelvic endometriosis: description \nand impact on surgical management. Hum Reprod 35: 1589-1600.\n18. Bendifallah S, Roman H, Rubod C, Leguevaque P , Watrelot A, et al. (2018) Impact of \nhospital and surgeon case volume on morbidity in colorectal endometriosis management: \na plea to define criteria for expert centers. Surg Endosc 32: 2003-2011. [crossref]\nCitation:\nGernot Hudelist and Joerg Keckstein (2020) How does Ttransvaginal Sonography Influence Surgical Strategies in Deep Endometriosis - The Role of the Classification \nSystem ENZIAN. Integr Gyn Obstet J Volume 3(2): 1-2.","source_license":"CC0","license_restricted":false}