Comparison Between Sonography-Based and Surgical Evaluation of Endometriotic Lesions Using the #Enzian Classification – A Retrospective Data Analysis

Alessandra Di Giovanni, A. Di Giovanni, Di Giovanni A, Eliana Montanari, Hudelist G, Gernot Hudelist, Malzoni M, Mario Malzoni, J. Keckstein, Joerg Keckstein
Ultraschall in der Medizin (Stuttgart, Germany : 1980) · 2022 · vol. 44(03) , pp. 290–298 · doi:10.1055/a-1713-3573 · PMID:35345051 · W4220853307
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

Transvaginal sonography accurately assesses the location and size of deep endometriosis lesions within Enzian compartments compared to surgical findings, providing a detailed preoperative description.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 · read from full text ⓘ

This retrospective study analyzed 93 women who underwent preoperative transvaginal sonography (TVS) and subsequent surgery for deep endometriosis in 2019 at a tertiary endometriosis center, comparing lesion location and size across #Enzian compartments with intraoperative assessment. The highest exact concordance was for compartment C (rectum) at 74%, rising to 87% when a maximum 3 mm TVS measurement tolerance was applied; compartments B and A had somewhat lower exact concordance, while compartment O showed high concordance and compartment T was most reliable for slight (T1) and severe adhesions (T3). The paper reports few missed lesions and generally high diagnostic performance, with sensitivity of 100% across most compartments except A/B left and FB, and specificity varying by compartment (e.g., 70% for B left). This paper is centrally about endometriosis — it compares TVS versus surgical extent using the #Enzian classification for deep endometriotic lesions.

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Abstract

PURPOSE: To compare the location and sizes of deep endometriosis (DE) lesions evaluated by preoperative transvaginal sonography (TVS) in different #Enzian compartments with intraoperatively assessed DE location and size. MATERIALS AND METHODS: Retrospective data analysis of 93 women undergoing TVS and surgery for DE in 2019 at a tertiary referral center for endometriosis. RESULTS: #Enzian compartment C (rectum) showed the highest rate of exact concordance with 74% of cases, which increased to 87% when a tolerance margin of a maximum of 3mm for TVS measurements was taken into account. For compartment B (uterosacral ligaments, parametria) and compartment A (vagina, rectovaginal space), the rates of exact concordance were slightly lower. In compartment O (ovary), high exact concordance rates similar to those observed for compartment C were observed. In compartment T (tubo-ovarian unit), most reliable estimations were seen for slight (TVS T1) and severe adhesions (TVS T3). There were only a few cases of missed lesions as well as false positives on TVS: Sensitivity was 100% for all compartments except for A and B left (97%) and FB (urinary bladder, 86%); specificity was 100% for FB, FI (other intestinal locations), FU (ureters) and O right, 86%-98% for A, B right, C, O left and FO (other extragenital lesions) and 70% for B left. CONCLUSION: The preoperative evaluation of the location and size of DE lesions by TVS in different #Enzian compartments is accurate, providing a detailed presurgical description of the extent of ovarian and deep endometriosis and associated minor or severe adhesions.
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Abstract

Purpose To compare the location and sizes of deep endometriosis (DE) lesions evaluated by preoperative transvaginal sonography (TVS) in different #Enzian compartments with intraoperatively assessed DE location and size.

Materials and methods

Retrospective data analysis of 93 women undergoing TVS and surgery for DE in 2019 at a tertiary referral center for endometriosis.

Results

#Enzian compartment C (rectum) showed the highest rate of exact concordance with 74% of cases, which increased to 87% when a tolerance margin of a maximum of 3mm for TVS measurements was taken into account. For compartment B (uterosacral ligaments, parametria) and compartment A (vagina, rectovaginal space), the rates of exact concordance were slightly lower. In compartment O (ovary), high exact concordance rates similar to those observed for compartment C were observed. In compartment T (tubo-ovarian unit), most reliable estimations were seen for slight (TVS T1) and severe adhesions (TVS T3). There were only a few cases of missed lesions as well as false positives on TVS: Sensitivity was 100% for all compartments except for A and B left (97%) and FB (urinary bladder, 86%); specificity was 100% for FB, FI (other intestinal locations), FU (ureters) and O right, 86%-98% for A, B right, C, O left and FO (other extragenital lesions) and 70% for B left.

Conclusion

The preoperative evaluation of the location and size of DE lesions by TVS in different #Enzian compartments is accurate, providing a detailed presurgical description of the extent of ovarian and deep endometriosis and associated minor or severe adhesions. Zusammenfassung Ziel Vergleich der Evaluierung mittels transvaginalem Ultraschall (TVUS) von Lokalisation und Größe tief infiltrierender Endometriose (TIE)-Läsionen mit der intraoperativen Evaluierung in verschiedenen #Enzian Kompartimenten.

Material

und Methoden Retrospektive Datenanalyse von 93 Frauen, die sich im Jahr 2019 in einem tertiären Endometriosezentrum nach TVUS einer chirurgischen TIE-Sanierung unterzogen. Ergebnisse #Enzian Kompartiment C (Rektum) zeigte die höchste Rate exakter Übereinstimmungen mit 74% der Fälle. Bei Berücksichtigung eines Toleranzbereichs für die TVUS-Messungen von max. 3mm stieg diese auf 87%. Für Kompartiment B (Uterosakral-ligamente, Parametrien) und Kompartiment A (Vagina, Septum rectovaginale) waren die Raten an exakten Übereinstimmungen etwas geringer. In Kompartiment O (Ovar) wurden hohe exakte Übereinstimmungsraten ähnlich wie Kompartiment C beobachtet. In Kompartiment T (tubo-ovarielle Einheit) zeigten sich die verlässlichsten Schätzungen für leichte (TVUS T1) und schwere Adhäsionen (TVUS T3). Es gab nur wenige Fälle übersehener Läsionen sowie falsch positiver Befunde: Die Sensitivität war für alle Kompartimente 100%, außer für A, B links (je 97%) und FB (Harnblase, 86%); die Spezifität war 100% für FB, FI (andere intestinale Lokalisationen), FU (Ureteren) und O rechts, 86%-98% für A, B rechts, C, O links und FO (andere extragenitale Läsionen) und 70% für B links. Schlussfolgerung Die präoperative Evaluierung von Lokalisation und Größe von TIE Läsionen mittels TVUS in verschiedenen #Enzian Kompartimenten ist akkurat und bietet eine detaillierte Beschreibung des Ausmaßes ovarieller und TIE sowie assoziierter leichter oder schwerer Adhäsionen.

Keywords

lesion size - preoperative evaluation - #Enzian classification - transvaginal sonography (TVS) - THEMES - surgeryPublication History Received: 03 July 2021 Accepted after revision: 26 November 2021 Article published online: 28 March 2022 © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany -

References

- 1 Chapron C, Dubuisson JB. Management of deep endometriosis. Ann N Y Acad Sci 2001; 943: 276-280 - 2 Koninckx PR, Meuleman C, Demeyere S. et al. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991; 55: 759-765 - 3 Fedele L, Bianchi S, Raffaelli R. et al. Pre-operative assessment of bladder endometriosis. Hum Reprod 1997; 12: 2519-2522 - 4 Keckstein J, Wiesinger H. Deep endometriosis, including intestinal involvement – the interdisciplinary approach. Minim Invasive Ther Allied Technol 2005; 14: 160-166 - 5 Keckstein J, Ulrich U, Possover M. et al. ENZIAN-Klassifikation der tief infiltrierenden Endometriose. Zentralbl Gynakol 2003; 125: 291 - 6 Keckstein J, Saridogan E, Ulrich UA. et al. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 2021; - 7 Guerriero S, Condous G, van den Bosch T. et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol 2016; 48: 318-332 - 8 Hudelist G, Montanari E, Salama M. et al. Comparison between Sonography-based and Surgical Extent of Deep Endometriosis Using the Enzian Classification – A Prospective Diagnostic Accuracy Study. J Minim Invasive Gynecol 2021;

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Outcome instruments

Enzian

Condition tags

endometriosis

MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Female Female Female Humans Humans Humans Rectum Rectum Rectum Rectum Retrospective Studies Retrospective Studies Retrospective Studies Sensitivity and Specificity

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