{"paper_id":"ff797cb2-7137-4b44-9511-e9f7f8a1e2e2","body_text":"Review began\n 10/14/2026 \nReview ended\n 10/19/2026 \nPublished\n 10/21/2026\n© Copyright \n2026\nMonzango Sibo et al. This is an open\naccess article distributed under the terms of\nthe Creative Commons Attribution License\nCC-BY 4.0., which permits unrestricted use,\ndistribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nDOI:\n 10.7759/cureus.118310\nLaparoscopic Endometriosis Phenotypes and\nPreoperative Non-suspicion of Endometriosis in\nWomen With Superficial Disease: A Retrospective\nStudy in Kinshasa\nGuy Lambert M. Monzango Sibo \n, \nLaetitia Itewa Monka \n1.\n Gynecology, University of Kinshasa, Kinshasa, COD \n2.\n Gynecology and Obstetrics, Cliniques Universitaires de\nKinshasa, Kinshasa, COD\nCorresponding author: \nGuy Lambert M. Monzango Sibo, \ndrguymonzango@gmail.com\nAbstract\nBackground\nSuperficial peritoneal endometriosis (SPE) is difficult to identify before surgery, especially without\nconcomitant ovarian or deep disease. We described laparoscopic phenotypes and examined factors\nassociated with the absence of documented preoperative suspicion of any endometriosis among women\nsubsequently found to have SPE.\nMethods\nWe retrospectively analyzed gynecologic laparoscopies performed at three Kinshasa sites between January\n2019 and June 2026 by one surgeon. Superficial, ovarian, and deep phenotypes were recorded as non-\nmutually exclusive. The analytical outcome was absence of documented preoperative suspicion of\nendometriosis of any phenotype among women with laparoscopically identified SPE and classifiable\npreoperative records. Modified Poisson models with robust variance estimated exploratory adjusted\nprevalence ratios (aPRs).\nResults\nOf 1,743 gynecologic laparoscopies, 216 (12.4%; 95% CI, 10.9%-14.0%) showed endometriosis and 1,527\n(87.6%) did not. SPE occurred in 139/216 (64.4%), ovarian disease in 137/216 (63.4%), and deep disease in\n68/216 (31.5%); 104/216 (48.1%) had overlapping phenotypes. Among 135 women with SPE whose\npreoperative records were classifiable, 83 (61.5%; 95% CI, 53.1%-69.3%) lacked documented suspicion of\nendometriosis; this proportion was 46/56 (82.1%) in isolated SPE. In the clinical model, infertility was\nassociated with higher non-suspicion (aPR 1.59; 95% CI, 1.07-2.35), while deep dyspareunia was associated\nwith lower non-suspicion (aPR 0.65; 95% CI, 0.45-0.94). With additional adjustment for coexisting operative\nphenotypes, the infertility association weakened (aPR 1.39; 95% CI, 0.95-2.04) and the dyspareunia estimate\nremained borderline (aPR 0.70; 95% CI, 0.49-1.00).\nConclusions\nSPE and ovarian disease were the most common laparoscopic phenotypes in this selected surgical cohort. An\nabsence of documented suspicion of any endometriosis was frequent among women with SPE, especially\nisolated SPE. Associations with infertility and deep dyspareunia are exploratory and may reflect clinical\ndocumentation, surgical referral pathways, and coexisting disease. Prospective standardized assessments\nare needed.\nCategories:\n Urology, Obstetrics/Gynecology, General Surgery\nKeywords:\n deep dyspareunia, endometrioma, infertility, kinshasa, laparoscopy, preoperative recognition, superficial\nperitoneal endometriosis\nIntroduction\nEndometriosis affects an estimated 10% of women of reproductive age and is associated with pelvic pain,\ndysmenorrhea, dyspareunia, infertility, and impaired quality of life \n[1]\n. Its anatomical phenotypes include\nsuperficial peritoneal endometriosis (SPE), ovarian endometrioma, and deep endometriosis \n[2]\n. Because\nthese phenotypes may coexist, their distribution and overlap are relevant to interpreting preoperative\nclinical suspicion.\nAlthough expert ultrasonography and magnetic resonance imaging can identify many ovarian and deep\nlesions, SPE remains more difficult to recognize. The European Society of Human Reproduction and\nEmbryology (ESHRE) emphasizes that negative imaging does not exclude endometriosis, particularly SPE \n[3]\n.\n1\n2\n \nOpen Access Original Article\nHow to cite this article\nMonzango Sibo G M, Itewa Monka L (October 21, 2026) Laparoscopic Endometriosis Phenotypes and Preoperative Non-suspicion of\nEndometriosis in Women With Superficial Disease: A Retrospective Study in Kinshasa. Cureus 18(10): e118310. \nDOI 10.7759/cureus.118310\n\nThe 2025 International Deep Endometriosis Analysis (IDEA) addendum proposes standardized sonographic\nassessment of superficial lesions \n[4]\n, but the frequency of documented preoperative suspicion in routine\nsurgical care remains poorly characterized.\nSymptoms do not resolve this uncertainty. In a 2026 multicenter study of symptomatic women with negative\nexamination and imaging, a symptom-based model for isolated SPE performed poorly in external validation\n(area under the curve, 0.49) \n[5]\n. However, predicting SPE rather than no endometriosis differs from assessing\nwhether endometriosis of any phenotype had been suspected before laparoscopy in women subsequently\nfound to have SPE. Coexisting ovarian or deep lesions may influence this recognition.\nThis distinction is relevant in Kinshasa, where phenotype-specific evidence is limited. A previous study of\n80 women with laparoscopically and histologically confirmed endometriosis reported a mean diagnostic\ndelay of approximately 12 years \n[6]\n but did not describe phenotype overlap across a broader laparoscopic\nseries or document preoperative suspicion among women with SPE. Consequently, it remains unclear\nwhether isolated SPE differs from overlapping phenotypes in its frequency of documented preoperative non-\nsuspicion.\nThe central problem is therefore not solely whether imaging can detect superficial lesions, but whether any\nendometriosis was documented as suspected before surgery in women with subsequently identified SPE.\nAbsence of documented suspicion is a record-based outcome, not proof that clinicians failed to consider\nendometriosis or a measure of the sensitivity of clinical assessment or imaging.\nThe primary objective was to describe the distribution and coexistence of superficial, ovarian, and deep\nendometriosis identified during gynecologic laparoscopy in Kinshasa. Secondary objectives were to estimate\nthe proportion of laparoscopies with identified endometriosis and, among women with SPE, to quantify the\nabsence of documented preoperative suspicion of endometriosis of any phenotype and explore associated\nclinical characteristics.\nMaterials And Methods\nStudy design and setting\nWe conducted a retrospective three-site analytical observational study of women undergoing gynecologic\nlaparoscopy between January 1, 2019, and June 30, 2026, at Onyx Medical Center (OMC), Clinique\nPrésidentielle de l’Union Africaine (CPUA), and Cliniques Universitaires de Kinshasa (CUK), Kinshasa,\nDemocratic Republic of the Congo.\nAll included laparoscopies were performed by the same experienced gynecologic laparoscopic surgeon using\na consistent approach to pelvic exploration and operative documentation. Operative reports were\nsystematically completed, laparoscopic photographs and/or videos were archived, and preoperative\nultrasound images were retained when available. The study was reported in accordance with Strengthening\nthe Reporting of Observational Studies in Epidemiology (STROBE) recommendations \n[7]\n.\nStudy population and analytical populations\nThe source cohort comprised all 1,743 gynecologic laparoscopies performed at the three participating\ncenters during the study period. No gynecologic laparoscopic procedure was excluded from the source cohort\nbefore analysis.\nThree nested analytical populations were defined: (1) all 1,743 gynecologic laparoscopies, including 216 with\nand 1,527 without laparoscopically identified endometriosis; (2) the 216 women with laparoscopically\nidentified endometriosis, used to characterize anatomical phenotypes; and (3) the 139 women with SPE, of\nwhom 135 had classifiable preoperative suspicion status and were included in the suspected-versus-\nunsuspected comparison. The 1,527 procedures without endometriosis were not excluded. The four women\nwith indeterminate preoperative documentation were retained in the descriptive analyses of endometriosis\nand its phenotypes but not included in the comparison by suspicion status.\nEligibility criteria and data sources\nThe study scope comprised gynecologic laparoscopies performed at the participating centers between\nJanuary 1, 2019, and June 30, 2026. All 1,743 procedures in this defined source population were included,\nwith zero exclusions. Procedures performed exclusively by laparotomy and operations for non-gynecologic\nindications were outside the study scope rather than exclusions from the laparoscopic cohort.\nData were extracted from operative registers, clinical records, preoperative consultations, ultrasound and\nmagnetic resonance imaging reports when available, archived ultrasound images, operative reports,\nlaparoscopic photographs/videos, and histopathology reports.\nPreoperative variables and suspicion status\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n2\n of \n10\n\nPreoperative variables included age, body mass index, infertility, dysmenorrhea, severe dysmenorrhea, pain\nduration longer than three years, chronic pelvic pain, deep dyspareunia, dyschezia, cyclical urinary\nsymptoms, previous pelvic surgery, and the principal surgical indication. Infertility status was taken from\nthe documented clinical variable and was not inferred solely from the operative indication.\nPreoperative suspicion was assessed exclusively from contemporaneous information recorded before\nsurgery. A woman was “suspected” when the record explicitly documented clinical suspicion or previously\nknown endometriosis, an endometrioma, suspected deep disease, or a positive preoperative ultrasound\nassessment of any endometriosis phenotype. A woman was “not documented as suspected” if her available\nrecord was considered classifiable and none of those indications were recorded. This definition concerns\nsuspicion of endometriosis generally, not specific preoperative recognition of superficial lesions. Cases\nwithout sufficiently interpretable documentation were marked indeterminate rather than presumed\nnegative. In a retrospective record review, absence of documentation cannot be equated with proof that a\nclinician did not consider the diagnosis.\nIn the harmonized analysis, a positive contemporaneous ultrasound report overrode a raw database label of\n“unsuspected”; the raw database classification was examined in a sensitivity analysis. The study did not\nformally measure diagnostic sensitivity, and retrospective review of archived ultrasound images was not\nused to redefine what the treating clinician knew before laparoscopy.\nLaparoscopic diagnosis and phenotype definitions\nEndometriosis was classified as laparoscopically identified when operative documentation described one or\nmore macroscopically compatible lesions. Photographs or videos were available to corroborate operative\ndescriptions. Histopathological confirmation was recorded separately; absence of tissue confirmation did\nnot automatically exclude macroscopically suspected disease. This approach may lead to phenotype\nmisclassification, particularly for superficial lesions.\nPhenotypes were defined according to international terminology \n[2]\n. SPE comprised lesions involving the\nperitoneal surface without operative evidence of deep infiltration. Ovarian endometriosis was defined by\none or more laparoscopically identified endometriomas. Deep endometriosis was defined by deep, nodular,\nor infiltrative disease involving structures such as the uterosacral ligaments/torus, retrocervical region,\nrectovaginal compartment, rectosigmoid, bladder, or ureter.\nThe three phenotypes were recorded independently and were not treated as mutually exclusive.\nCombinations were subsequently derived as isolated superficial, isolated ovarian, isolated deep, superficial\nplus ovarian, superficial plus deep, ovarian plus deep, and simultaneous superficial, ovarian, and deep\ndisease.\nUltrasound archives and the IDEA 2025 framework\nArchived preoperative ultrasound images were available for most women with endometriosis. However, the\ncomplete 2025 IDEA protocol for SPE was not retrospectively reconstructed because examinations\nperformed before publication of the consensus had not systematically captured all dynamic components,\nincluding site-specific tenderness, ovarian mobility, organ sliding, and standardized real-time scanning\nmaneuvers \n[4]\n. The original contemporaneous ultrasound interpretation, rather than retrospective\nreinterpretation after knowledge of surgery, was used to define preoperative suspicion.\nOutcomes\nThe principal descriptive outcome was anatomical phenotype distribution. The analytic outcome was\nabsence of documented preoperative suspicion of endometriosis of any phenotype among women with SPE\nand classifiable records; it was not a measure of diagnostic sensitivity for SPE specifically. Secondary\noutcomes included overlapping phenotypes, lesion sites, histological confirmation, and exploratory\nassociations between documented clinical characteristics and non-suspicion.\nStatistical analysis\nAnalyses were performed using Python 3.13.5 (Python Software Foundation, Wilmington, DE) with\nStatsmodels 0.14.6, SciPy 1.17.0, NumPy 2.3.5, and pandas 2.2.3. Continuous variables were summarized as\nmean ± standard deviation and categorical variables as counts and percentages. Proportions were\naccompanied by 95% confidence intervals.\nContinuous characteristics were compared using Student’s t-test and categorical characteristics using chi-\nsquare or Fisher’s exact tests, as applicable. Given the common binary outcome, modified Poisson regression\nwith robust variance was used to estimate adjusted prevalence ratios (APRs) and 95% confidence intervals\n[8]\n. Associations were interpreted within this selected surgical cohort rather than causally.\nThe primary clinical model included age, infertility, severe dysmenorrhea, pain duration over three years,\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n3\n of \n10\n\ndeep dyspareunia, and dyschezia, selected for clinical relevance and preoperative availability rather than\nunivariable significance. Coexisting operative phenotypes were omitted from the primary clinical model\nbecause they were not established preoperatively; an extended explanatory model included ovarian and deep\ndisease. Interpretation must account for possible collinearity, documentation bias, and referral/surgical-\nindication selection.\nReported sensitivity analyses used (1) unharmonized database suspicion status, (2) histologically confirmed\nSPE, (3) availability of operative video, and (4) additional adjustment for ovarian and deep phenotypes. The\nmanuscript reports a two-sided significance threshold of 0.05; near-threshold estimates should be\ninterpreted by effect size and interval precision rather than as binary evidence.\nData validation and missingness\nAll 1,743 gynecologic laparoscopies in the source cohort were included without exclusions: 216 showed\nlaparoscopically identified endometriosis, and 1,527 did not. Among the 139 women with SPE, four had\nindeterminate preoperative suspicion status; these women remained in the descriptive cohort, while 135\nclassifiable records contributed to the comparison of preoperative suspicion. The six covariates used in the\nprimary regression model were complete in those 135 records. Descriptive and regression analyses were\nperformed using the analytical dataset; primary patient records were not independently reabstracted for this\nanalysis.\nEthical considerations\nThe study was approved by the Ethics Committee of the School of Public Health, University of Kinshasa\n(approval number ESP/CE/769/2026). The analysis used retrospective clinical and operative data.\nResults\nStudy population and frequency of endometriosis\nAll 1,743 gynecologic laparoscopies performed at the three centers during the study period were included,\nwith no procedures excluded before analysis. Endometriosis was identified in 216 (12.4%; 95% CI, 10.9%-\n14.0%), while the other 1,527 procedures (87.6%) showed no laparoscopically identified endometriosis. OMC\ncontributed 1,275 laparoscopies, including 158 endometriosis cases (12.4%), and CPUA contributed 464\nlaparoscopies, including 57 cases (12.3%); these proportions did not differ (p = 0.952). CUK contributed four\nlaparoscopies, including one case; no center-specific inference was made because of this very small\ndenominator.\nThere was no statistically significant temporal change in the probability of identifying endometriosis across\nthe study period (OR per calendar year 1.06; 95% CI, 0.99-1.13; p = 0.108).\nPatient characteristics and the principal surgical indications are presented in Table \n1\n.\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n4\n of \n10\n\nCharacteristic\nn (%) or mean ± SD\nAge, years\n31.7 ± 6.2\nBody mass index, kg/m²\n25.7 ± 3.9\nInfertility\n140 (64.8%)\nDysmenorrhea\n177 (81.9%)\nSevere dysmenorrhea\n99 (45.8%)\nChronic pelvic pain\n85 (39.4%)\nDeep dyspareunia\n71 (32.9%)\nDyschezia\n28 (13.0%)\nCyclical urinary symptoms\n22 (10.2%)\nPrevious pelvic surgery\n48 (22.2%)\nInfertility/tuboperitoneal assessment\n72 (33.3%)\nAdnexal cyst or mass\n59 (27.3%)\nPelvic pain\n51 (23.6%)\nHydrosalpinx/other tubal disease\n19 (8.8%)\nUterine leiomyoma\n8 (3.7%)\nOther gynecologic indication\n4 (1.9%)\nEctopic pregnancy\n3 (1.4%)\nTABLE\n 1: Clinical characteristics and principal surgical indications among women with\nlaparoscopically identified endometriosis (n = 216)\nDistribution of laparoscopic phenotypes\nSPE was identified in 139/216 women (64.4%; 95% CI, 57.8%-70.4%), ovarian endometriosis in 137/216\n(63.4%; 95% CI, 56.8%-69.6%), and deep endometriosis in 68/216 (31.5%; 95% CI, 25.7%-38.0%). Because\nphenotypes could coexist, individual phenotype percentages were not mutually exclusive.\nAt least two phenotypes were present in 104/216 women (48.1%).\nThe distribution and overlap of anatomical phenotypes are summarized in Table \n2\n.\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n5\n of \n10\n\nPhenotype\nn (%)\nSuperficial peritoneal endometriosis\n139 (64.4%)\nOvarian endometriosis\n137 (63.4%)\nDeep endometriosis\n68 (31.5%)\nIsolated superficial\n58 (26.9%)\nIsolated ovarian\n46 (21.3%)\nIsolated deep\n8 (3.7%)\nSuperficial + ovarian\n44 (20.4%)\nSuperficial + deep\n13 (6.0%)\nOvarian + deep\n23 (10.6%)\nSuperficial + ovarian + deep\n24 (11.1%)\n≥2 phenotypes\n104 (48.1%)\nTABLE\n 2: Distribution and overlap of laparoscopic endometriosis phenotypes\nThe first three phenotype categories are non-mutually exclusive; the seven phenotype-combination categories are mutually exclusive.\nThe posterior peritoneum was involved in 111/216 women (51.4%), followed by the left ovary in 90 (41.7%),\nanterior peritoneum in 82 (38.0%), right ovary in 78 (36.1%), and uterosacral ligament/torus region in 53\n(24.5%). Retrocervical, rectosigmoid, and bladder involvement were documented in 20 (9.3%), 18 (8.3%),\nand six women (2.8%), respectively.\nOperative video was available in 212/216 cases (98.1%) and archived preoperative ultrasound images in\n200/216 (92.6%). Biopsy or excision was performed in 182 women; histology confirmed endometriosis in\n166/182 sampled cases (91.2%), representing 76.9% of all laparoscopically identified cases.\nPreoperative non-suspicion of superficial peritoneal endometriosis\nAmong 139 women with laparoscopically identified SPE, preoperative documentation was classifiable in\n135: 83 had no documented suspicion of endometriosis of any phenotype, 52 had documented suspicion,\nand four were indeterminate. Thus, non-suspicion was recorded in 83/135 (61.5%; 95% CI, 53.1%-69.3%).\nThis is a measure of documentation-defined recognition among operated patients, not the false-negative\nrate of clinical examination or imaging.\nNon-suspicion varied across phenotype combinations (reported p < 0.001): 46/56 (82.1%) in isolated SPE,\n24/44 (54.5%) in superficial-plus-ovarian disease, 5/13 (38.5%) in superficial-plus-deep disease, and 8/22\n(36.4%) when all three phenotypes coexisted. The denominator of 56 isolated cases reflects exclusion of two\nindeterminate records from 58 laparoscopically identified isolated SPE cases; the other two indeterminate\nrecords were in the triple-phenotype category (24 total, 22 classifiable). The crude reported prevalence ratio\nfor isolated versus coexisting SPE was 1.75 (95% CI, 1.35-2.29; p < 0.001). These contrasts partly reflect the\noutcome definition: ovarian or deep lesions can themselves prompt suspicion of endometriosis.\nClinical characteristics associated with preoperative non-suspicion\nPreoperative clinical characteristics by documented suspicion status are compared in Table \n3\n.\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n6\n of \n10\n\nVariable\nUnsuspected (n = 83)\nSuspected (n = 52)\np-value\nAge, years\n30.9 ± 5.9\n32.3 ± 6.0\n0.212\nBody mass index, kg/m²\n25.7 ± 4.2\n25.9 ± 3.8\n0.698\nInfertility\n67 (80.7%)\n30 (57.7%)\n0.004\nSevere dysmenorrhea\n37 (44.6%)\n25 (48.1%)\n0.691\nPain duration >3 years\n34 (41.0%)\n23 (44.2%)\n0.708\nChronic pelvic pain\n28 (33.7%)\n23 (44.2%)\n0.221\nDeep dyspareunia\n18 (21.7%)\n24 (46.2%)\n0.003\nDyschezia\n10 (12.0%)\n9 (17.3%)\n0.392\nCyclical urinary symptoms\n11 (13.3%)\n3 (5.8%)\n0.165\nPrevious pelvic surgery\n13 (15.7%)\n12 (23.1%)\n0.28\nTABLE\n 3: Preoperative characteristics according to suspicion status among women with\nsuperficial peritoneal endometriosis\nValues are n (%) unless otherwise indicated.\nInfertility was more frequent among women with unsuspected SPE than among women with suspected SPE\n(80.7% vs. 57.7%; p = 0.004), whereas deep dyspareunia was less frequent (21.7% vs. 46.2%; p = 0.003). No\nstatistically significant differences were observed for age, body mass index, severe dysmenorrhea, symptom\nduration longer than three years, chronic pelvic pain, dyschezia, cyclical urinary symptoms, or previous\npelvic surgery.\nMultivariable analysis\nThe primary multivariable estimates are presented in Table \n4\n.\nVariable\naPR\n95% CI\np-value\nAge, per year\n0.99\n0.97-1.01\n0.22\nInfertility\n1.59\n1.07-2.35\n0.022\nSevere dysmenorrhea\n0.94\n0.73-1.21\n0.618\nPain duration >3 years\n0.93\n0.72-1.20\n0.572\nDeep dyspareunia\n0.65\n0.45-0.94\n0.022\nDyschezia\n0.91\n0.57-1.43\n0.673\nTABLE\n 4: Primary modified Poisson regression for absence of documented preoperative\nsuspicion of endometriosis among women with superficial peritoneal disease\nThis exploratory model included only recorded preoperative clinical variables. The endpoint was absence of documented suspicion of any endometriosis\namong women with SPE, not specific non-detection of SPE.\naPR: adjusted prevalence ratio; CI: confidence interval\nIn the primary clinical model, infertility was associated with more frequent documentation-defined non-\nsuspicion (aPR 1.59; 95% CI, 1.07-2.35; p = 0.022) and deep dyspareunia with less frequent non-suspicion\n(aPR 0.65; 95% CI, 0.45-0.94; p = 0.022). These estimates are exploratory and are not evidence that infertility\ncauses missed diagnosis or that dyspareunia increases test accuracy.\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n7\n of \n10\n\nSensitivity analyses\nThe sensitivity analysis estimates are presented in Table \n5\n.\nAnalysis\nInfertility, aPR (95% CI); p\nDeep dyspareunia, aPR (95% CI); p\nPrimary harmonized status (n = 135)\n1.59 (1.07-2.35); p = 0.022\n0.65 (0.45-0.94); p = 0.022\nRaw database status (n = 134)\n1.71 (1.16-2.52); p = 0.007\n0.69 (0.49-0.96); p = 0.028\nHistologically confirmed SPE (n = 102)\n1.61 (1.06-2.44); p = 0.026\n0.69 (0.47-1.00); p = 0.050\nOperative video available (n = 132)\n1.65 (1.09-2.49); p = 0.017\n0.68 (0.47-0.98); p = 0.037\nAdditional adjustment for ovarian/deep phenotype (n = 135)\n1.39 (0.95-2.04); p = 0.091\n0.70 (0.49-1.00); p = 0.047\nTABLE\n 5: Sensitivity analyses for the two principal clinical associations\naPR: adjusted prevalence ratio; SPE: superficial peritoneal endometriosis\nThe infertility association was similar in analyses using raw database labels and restricted to histologically\nconfirmed or video-documented SPE; it attenuated after adjustment for coexisting ovarian/deep disease\n(aPR 1.39; 95% CI, 0.95-2.04; p = 0.091). In the extended model, deep dyspareunia had a near-threshold\nestimate (aPR 0.70; 95% CI, 0.49-1.00 after rounding; p = 0.047). Coexisting deep disease was associated\nwith less frequent documented non-suspicion (aPR 0.60; 95% CI, 0.39-0.92; p = 0.020), although this\nassociation may partly reflect the operational definition of clinical suspicion.\nThere was no statistically significant temporal trend in SPE non-suspicion over the study period (prevalence\nratio per calendar year 0.97; 95% CI, 0.91-1.03; p = 0.279). \nDiscussion\nThis surgical cohort describes the overlap of laparoscopically identified phenotypes in Kinshasa.\nEndometriosis was identified in approximately one of eight eligible laparoscopies, and nearly half of the\nidentified cases exhibited multiple phenotypes. Among women with SPE and classifiable records, 61.5% had\nno documented preoperative suspicion of endometriosis of any phenotype. Non-suspicion was especially\nfrequent with isolated superficial disease. These findings describe recognition documented within a selected\noperative pathway, not population prevalence or imaging sensitivity.\nThe 12.4% proportion should not be interpreted as the population prevalence of endometriosis in Kinshasa.\nThe denominator consisted of women selected for gynecologic laparoscopy and therefore reflects surgical\nindications, referral pathways, and access to minimally invasive surgery. Nevertheless, the almost identical\nproportions observed at OMC and CPUA and the absence of a significant temporal trend suggest that the\noverall estimate was not driven by a single high-volume period or by one of the two principal sites.\nThe phenotype distribution reinforces the anatomical heterogeneity of endometriosis. International\nterminology treats superficial, ovarian, and deep disease as distinct but potentially coexisting forms \n[2]\n. In\nour series, 48.1% of women had at least two phenotypes. This is consistent with prospective data\ndemonstrating substantial coexistence of lesion types among women undergoing surgery for endometriosis-\nassociated infertility \n[9]\n. Recording each phenotype independently therefore provides more informative\nanatomical characterization than forcing every patient into a single mutually exclusive category.\nDocumented preoperative suspicion was less frequent in women with isolated SPE than in those with\ncoexisting ovarian or deep disease. This is compatible with the recognized imaging challenges of superficial\nlesions \n[3,4]\n, but the study did not apply a standardized preoperative imaging protocol and cannot estimate\nthe performance of ultrasonography. Furthermore, the endpoint deliberately counts suspicion of an\nendometrioma or deep endometriosis as suspicion of endometriosis, whether or not a superficial lesion was\nseparately recognized. Hence, differences by phenotype combination may partly arise from the classification\nrule itself.\nInfertility was more common in women without documented preoperative suspicion (80.7%) than in those\nwith documented suspicion (57.7%). The clinical model indicated an association, but operated infertility\npatients may reach laparoscopy for tuboperitoneal investigations without a recorded endometriosis\nhypothesis. Consequently, referral pathways and surgery indication are plausible sources of selection bias;\ninfertility should not be regarded as an independently validated diagnostic marker for SPE.\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n8\n of \n10\n\nAn association between superficial endometriosis and infertility is biologically and clinically plausible. Reis\net al. compared 203 women with isolated histologically confirmed SPE with 1,292 endometriosis-free\ncontrols and found an independent association with primary infertility, as well as dysmenorrhea and deep\ndyspareunia \n[10]\n. Their outcome, however, was the presence of SPE, whereas our outcome was preoperative\nrecognition among women who already had SPE. These questions are related but not equivalent.\nThe association of infertility weakened when coexisting ovarian and deep phenotypes were included. This\nextended adjustment is explanatory and does not identify a causal pathway because operative anatomy and\npreoperative recognition are linked by the outcome definition, and selection into surgery may depend on\nsymptoms and imaging. The numerical association should therefore be presented as hypothesis-generating\nrather than robust evidence of an independent effect.\nDeep dyspareunia was less frequently documented among women without preoperative suspicion and\nshowed an exploratory association with greater likelihood of documented recognition. Clinicians may be\nmore inclined to consider endometriosis when dyspareunia is recorded, but different elicitation or recording\nof symptoms could generate this pattern. The extended estimate (aPR 0.70, p = 0.047) is close to the\nconventional threshold, and the confidence interval rounds to 1.00, requiring cautious interpretation.\nOur results also differ in an informative way from the 2026 study by Reiser et al. \n[5]\n. In that study, severe\ndysmenorrhea and pain lasting more than three years were associated with isolated SPE in women with\nnegative examination and imaging, but the prediction model performed poorly during external validation.\nIn our analysis, neither severe dysmenorrhea nor prolonged pain duration was independently associated\nwith preoperative non-suspicion. This does not represent failed replication because the outcomes are\ndifferent: Reiser et al. attempted to distinguish SPE from no endometriosis, whereas we compared\nrecognized with unrecognized disease among women with SPE. Together, the studies argue against relying\non a single symptom profile to identify superficial disease.\nThe findings are relevant to the local diagnostic context. A previous Kinshasa study documented an average\ndiagnostic delay of approximately 12 years among women with surgically and histologically confirmed\nendometriosis \n[6]\n. The present study extends that observation by identifying isolated superficial disease as a\nphenotype particularly vulnerable to preoperative non-recognition. Improving detection in this setting will\nlikely require standardized history-taking, awareness of infertility-associated presentations, and dedicated\nultrasound approaches rather than symptom screening alone.\nThis study has several strengths. The denominator comprised 1,743 gynecologic laparoscopies over more\nthan seven years. All procedures were performed by the same experienced surgeon, reducing inter-surgeon\nvariability in pelvic exploration and recognition of lesions. Operative videos were available for 98.1% of\nendometriosis cases and archived ultrasound images for 92.6%. Phenotypes were analyzed as potentially\ncoexisting rather than mutually exclusive. Finally, the principal associations were examined across several\nsensitivity analyses, including histologically confirmed and video-documented subsets.\nImportant limitations include the retrospective, documentation-dependent definition of suspicion,\nunavailable information on assessor masking and documentation-completeness rules, and the possibility\nthat absence of a chart entry does not indicate absence of clinical suspicion. The endpoint refers to suspicion\nof any endometriosis among women with SPE, not to recognition of the superficial phenotype specifically.\nReferral pathways and surgical indications may have introduced selection bias, and findings cannot be\ngeneralized to the population of Kinshasa. Not all macroscopic lesions underwent histopathological\nconfirmation, and blinded independent video review was not performed. Almost all procedures came from\ntwo centers, while the third contributed four; all were performed by a single surgeon. The full IDEA 2025\ndynamic ultrasound protocol was not used systematically during the study period. The near-threshold\nfinding for dyspareunia and attenuation of the infertility association after phenotype adjustment discourage\ncausal or diagnostic interpretations.\nThe present data should therefore be considered hypothesis-generating rather than sufficient for a\ndiagnostic score. A prospective multicenter study should collect symptoms, infertility characteristics,\nexamination findings, and IDEA-informed ultrasound features before surgery and without knowledge of\nlaparoscopic findings. Such a design could test whether reproductive context adds clinically meaningful\ninformation to standardized imaging and could externally validate any resulting prediction model in an\nindependent Congolese population.\nConclusions\nAmong selected gynecologic laparoscopies performed in Kinshasa, superficial and ovarian endometriosis\nwere frequently identified, and anatomical phenotype overlap was common. Of women with superficial\nperitoneal lesions and classifiable preoperative records, a substantial proportion lacked documented\nsuspicion of endometriosis of any phenotype, most frequently when superficial disease was isolated.\nAssociations with infertility and deep dyspareunia warrant cautious interpretation because documentation,\nreferral pathways, and coexisting operative phenotypes could affect the findings. Prospective studies using\n \n2026 Monzango Sibo et al. Cureus 18(10): e118310. DOI 10.7759/cureus.118310\n9\n of \n10\n\nstandardized clinical recording and dedicated preoperative ultrasound assessment are required to\ninvestigate recognition of superficial lesions specifically.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nGuy Lambert M. Monzango Sibo, Laetitia Itewa Monka\nAcquisition, analysis, or interpretation of data:\n  \nGuy Lambert M. Monzango Sibo, Laetitia Itewa Monka\nDrafting of the manuscript:\n  \nGuy Lambert M. Monzango Sibo, Laetitia Itewa Monka\nCritical review of the manuscript for important intellectual content:\n  \nGuy Lambert M. Monzango Sibo,\nLaetitia Itewa Monka\nSupervision:\n  \nGuy Lambert M. Monzango Sibo\nDisclosures\nHuman subjects:\n Informed consent for treatment and open access publication was obtained or waived by all\nparticipants in this study. Comite d’Ethique, Ecole de Sante Publique, Université de Kinshasa issued\napproval ESP/CE/769/2026. \nAnimal subjects:\n All authors have confirmed that this study did not involve\nanimal subjects or tissue. \nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all\nauthors declare the following: \nPayment/services info:\n All authors have declared that no financial support\nwas received from any organization for the submitted work. \nFinancial relationships:\n All authors have\ndeclared that they have no financial relationships at present or within the previous three years with any\norganizations that might have an interest in the submitted work. \nOther relationships:\n All authors have\ndeclared that there are no other relationships or activities that could appear to have influenced the\nsubmitted work.\nAcknowledgements\nChatGPT (OpenAI, San Francisco, CA) was used to assist with English-language editing, manuscript\norganization, methodological critique, and statistical code drafting. The authors retained responsibility for\nstudy design, clinical data, statistical verification, interpretation, and final manuscript content.\nReferences\n1\n. \nWorld Health Organization: Endometriosis\n. (2025). Accessed: October 8, 2026: \nhttps://www.who.int/news-\nroom/fact-sheets/detail/endometriosis\n.\n2\n. \nInternational Working Group of AAGL, ESGE, ESHRE and WES, Tomassetti C, Johnson NP, et al.: \nAn\ninternational terminology for endometriosis, 2021\n. Hum Reprod Open. 2021, 2021:hoab029.\n10.1093/hropen/hoab029\n3\n. \nBecker CM, Bokor A, Heikinheimo O, et al.: \nESHRE guideline: endometriosis\n. Hum Reprod Open. 2022,\n2022:hoac009. \n10.1093/hropen/hoac009\n4\n. \nGuerriero S, Condous G, Rolla M, et al.: \nAddendum to consensus opinion from the International Deep\nEndometriosis Analysis (IDEA) group: sonographic evaluation of superficial endometriosis\n. 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