Role of 3D transvaginal ultrasound in predicting surgical technique in patients with rectal deep infiltrating endometriosis

Background Endometriosis is a common and challenging gynecological disease that has a great impact on women’s quality of life. Deep infiltrating endometriosis (DIE) involving the bowel poses a significant challenge to the gynecologist. Transvaginal sonography (TVS) is an established first-line imaging tool in the evaluation of the extent of rectosigmoid endometriosis extent before surgery. The aim of this study is to evaluate the ability of preoperative 3D TVS measurements in predicting surgical technique in patients with rectosigmoid DIE. This retrospective study included all consecutive patients who underwent TVS followed by laparoscopic surgery for rectal DIE from October 2021 to February 2024. The length, thickness, and circumference involvement of the rectal nodules were recorded using 2D and 3D TVS for each bowel lesion and compared with postoperative outcomes.

Fifty-one bowel surgeries were performed: four (7.8%) segmental resections, 18 (35.3%) disc excisions, 28 (54.9%) bowel shavings, and one case (2.0%) of double disc excision for multicentric lesions more than 4 cm apart. According to 3D TVS measurements, none of the patients who underwent segmental resection had a length 50%. All patients who had shaving or disc excision had a length < 3 cm with a mean longitudinal diameter of 2.1 cm and 2.9 cm, respectively. An average thickness of 4.8 mm, 7.8 mm, and 9.0 mm was observed for nodules that were treated by shaving, disc excision, and segmental resection, respectively. A circumference involvement cutoff value of 50% was appropriate for disc excision. We had 13 (25.4%) cases of rectal DIE without endometriomas and two (3.9%) cases in which the bowel was the only site of DIE involvement. A cutoff value of 3.5 cm for lesion length and 8 mm for lesion thickness was predictive for segmental bowel resection with an area under the curve (AUC) of 0.959 and 0.908, respectively.

3D TVS provides an accurate and thorough evaluation of the extent of rectosigmoid endometriosis. Preoperative assessment of the length, thickness, and circumference involvement can help decide whether segmental bowel resection or a conservative approach is required. Similar content being viewed by others

Endometriosis is a common gynecological disease affecting up to 1 in 10 women of childbearing age [1]. Despite being a benign condition, the accompanying symptoms and chronic nature of this disease make it a major ongoing medical, social, and economic problem [2]. Deep infiltrating endometriosis (DIE), which makes up one-third of all endometriosis cases, is characterized by the presence of an ectopic endometriotic growth, fibrosis, and hyperplasia of the smooth muscle below the peritoneum by 5 mm in depth [3, 4]. Intestinal involvement is one of the severe manifestations of endometriosis, amounting to 12% of cases of DIE, with almost 90% of these affecting the rectosigmoid bowel alone [3, 5,6,7]. DIE involving the bowel presents a special challenge for the treating gynecologist. Intestinal DIE has been reported to have an increased incidence of surgical complications, a greater impact on pain, and potential bowel obstruction [8]. Timely and accurate diagnosis is crucial for patient management and preoperative planning to assess the complexity of surgery and potential complications [9]. Studies have shown that the size of rectal and rectosigmoid DIE nodules affects the extent and type of surgery and the risk of associated postoperative complications [10]. The current surgical techniques available for treatment of rectal DIE include nodulectomy (shaving and discoid resection) and segmental bowel resection, with a 2.2%, 9.7%, and 9.9% risk of complications for each technique, respectively [11]. Transvaginal sonography (TVS) is a well-established first-line imaging modality in the assessment of the extent of pelvic and deep infiltrating endometriosis [12, 13]. Advances in ultrasound technology and new built-in 3D reconstruction applications have further enhanced the diagnostic role of ultrasound imaging in determining the true extent of disease, potentially allowing accurate measurements of the length, depth, and circumference of rectal involvement [14]. This retrospective study aims to assess the ability of preoperative 3D TVS measurements in predicting surgical technique in patients with rectal and rectosigmoid DIE.

Our retrospective study included an electronic medical record review of all consecutive patients who underwent TVS followed by laparoscopic surgery for rectal DIE from October 2021 to February 2024. Institutional ethics committee approval was obtained. A waiver of informed consent was granted due to the retrospective study design. The study was reported in accordance with Standards for Reporting for Diagnostic accuracy studies (STARD guidelines). Inclusion criteria included all consecutive women who underwent TVS or transrectal sonography (TRS) at our institution and were diagnosed with rectal DIE followed by laparoscopic surgery. Exclusion criteria included patients who declined TVS or TRS examinations, patients who underwent the ultrasound examinations at an outside institution or underwent MRI only, patients who were unfit or opted out surgery, and patients with incomplete electronic medical records. Rectal DIE was suspected clinically based on physical examination and a detailed clinical history. A data collection sheet was obtained for all the cases by the gynecologist, which included patients’ symptoms, previous surgical and medical treatments, parity, and infertility. Visual analog score (VAS) was documented for all patients from 0 to 10, where 0 corresponds to absence of pain while 10 is the most severe pain. Ultrasound examination The ultrasound examinations were performed by the transvaginal approach, and in the case of virgin females or patients with technical difficulties, the transrectal approach was used. The examinations were performed using the (Voluson E8 GE Healthcare) ultrasound machine using a 3D 5–9 MHz transvaginal endocavity probe. The examination was done without bowel preparation and with a partially filled urinary bladder at any phase of the menstrual cycle. Standard 2D and 3D volume image acquisition by the volume contrast imaging (VCI) and tomographic ultrasound imaging (TUI) were acquired to give the reconstructed sagittal, axial and coronal images. All ultrasound examinations were performed by two highly experienced radiologists in the imaging of women with endometriosis. The time between the ultrasound examination and surgery was limited to a maximum of four weeks. At our institution, we follow the standardized ultrasound imaging protocol in patients with clinically suspected endometriosis in four basic steps in accordance with the International Deep Endometriosis Analysis (IDEA) group which starts with assessment of the uterus for signs of adenomyosis then adnexal endometriosis for ovarian endometriomas followed by Douglas pouch obliteration and finally mapping of DIE in different compartments [13]. A key approach in searching for DIE is the tenderness-guided ultrasound technique which guides the radiologist to DIE locations [15]. Rectal wall involvement appeared as an irregularly shaped hypoechoic wall thickening of the bowel that may result in bowel lumen compromise [16]. The length, thickness, and circumference involvement of the rectal nodules were recorded using 2D and 3D TVS or TRS for each bowel lesion and compared with postoperative outcomes. The maximum length and thickness were calculated from the 2D or reconstructed TUI sagittal images of the bowel lesion, while circumference involvement was calculated from the reconstructed TUI axial images of the bowel by dividing the perimeter of the rectal lesion by the perimeter of the whole rectal segment at the same level. The length, thickness, and circumference measurements of rectal DIE lesions measured by ultrasound are shown in (Fig. 1). The rectal DIE was subdivided into cranial and caudal rectal involvement using the uterosacral ligament level as an anatomic landmark. Lesions above the uterosacral ligaments were considered cranial rectal, whereas nodules below the ligaments were considered caudal rectal lesions [17]. Surgery All cases underwent a laparoscopic surgical approach, with none of the cases converted to laparotomy. All cases were operated by the same senior gynecological surgeon who had specific training in the surgical management of deep infiltrating endometriosis cases by laparoscopy; some cases were carried out with the assistance of a senior colorectal surgeon. Our standard surgical technique involved six steps following the mnemonic AADEOS: assessment, adhesiolysis, drainage/stripping of endometriomas, exposure of the lesion and surrounding vital structures, opening of pelvic spaces and fascial planes relevant to the location of the rectal nodule, and finally surgical excision. Rectal nodules were excised using the shaving technique, rectal disc excision, or segmental bowel resection according to the size of the rectal bowel involvement and whether luminal occlusion was present. After surgery all the surgical specimens were transferred to the institution’s pathology department for histopathological confirmation. Statistical analysis Data were statistically described in terms of mean ± standard deviation (± SD), median, range, or frequencies (number of cases) and percentages when appropriate. Because the groups are small in size, a comparison of numerical variables between the study groups was done using the Mann–Whitney U test for independent samples for comparing the 2 groups and the Kruskal–Wallis test for comparing more than 2 groups. For comparing categorical data, Chi-square (c2) test was performed. Exact tests were used instead when the expected frequency is less than 5. Accuracy was represented using the terms “sensitivity,” “specificity,” “ + ve predictive value,” “ − ve predictive value,” and “overall accuracy.” Receiver operator characteristic (ROC) analysis was used to determine the optimum cutoff value for ultrasound measures of lesion length and thickness in predicting the type of surgery. Two-sided p values less than 0.05 were considered statistically significant. IBM SPSS (Statistical Package for the Social Sciences; IBM Corp., Armonk, NY, USA) release 22 for Microsoft Windows was used for all statistical analyses.

Of the 229 laparoscopic surgeries for DIE completed between October 2021 and February 2024, a total of 201 cases had preoperative TVS or TRS sonographic findings, and a complete assessment of the data was carried out. Following the exclusion criteria, 51 patients who underwent surgery for rectal DIE were included in our study. Table 1 summarizes the characteristics of the study population, and Table 2 shows the sensitivity, specificity, and accuracy of the ultrasound examination in different DIE sites considering laparoscopy and histopathology as the gold standard. There were two cases (3.9%) in which the rectum was the only site of DIE involvement. Fifty-one bowel surgeries were performed: four (7.8%) segmental resections, 18 (35.3%) disc excisions, 28 (54.9%) bowel shavings, and one case (2.0%) of double disc excision for multicentric lesions more than 4 cm apart. The cranial rectum was involved in 17 cases (33.3%), while the caudal rectum was involved in 34 cases (66.7%). Thirty-eight out of 51 cases (74.5%) were associated with ovarian endometriomas, 14 of which (36.8%) were right-sided, 10 (26.3%) were left-sided, and in 14 cases (36.8%) the endometriomas were bilateral. Rectal lesions, which were excised by segmental resection, had a longitudinal diameter ranging from 3.5 to 5.6 cm with a mean of 4.5 cm, with none of the lesions < 3.5 cm, while all the lesions that were excised by shaving and disc excision had a longitudinal diameter < 3 cm with a mean longitudinal diameter of 2.1 cm and 2.9 cm, respectively. There was a significant statistical difference (p = 0.002) in the length of lesions excised by segmental resection and nodulectomy (shaving and disc excision) (Figs. 2 and 3). The mean thickness of the rectal lesions measured by TVS was 9.0 mm ± 0.82 mm (SD), 4.8 mm ± 1.2 mm (SD), and 7.8 mm ± 1.3 mm (SD) for rectal lesions excised by segmental resection, shaving, and disc excision, respectively, with a significant statistical difference (p = 0.007) between segmental resection and nodulectomy (shaving and disc excision). None of the lesions treated with segmental resection had a thickness 50%, while 47 (92.2%) lesions had a circumference ≤ 50%. Three out of 4 cases (75%) of lesions treated with segmental resection had a circumference > 50%; one lesion, which was treated with disc excision, had a circumference of 50%, while none of the 28 cases of bowel shaving had a circumference > 50% with a significant statistical difference (p = 0.001) between segmental resection and nodulectomy (shaving and disc excision). The ROC curve in (Fig. 5) indicates that a cutoff value of 3.5 cm for lesion length and 8 mm for lesion thickness were predictive for segmental bowel resection with an area under the curve (AUC) of 0.959 and 0.908, respectively. No major intraoperative or postoperative complications were recorded, which reflects proper preoperative planning and a multidisciplinary approach.

Rectosigmoid DIE is one of the most severe manifestations of endometriosis and the most prevalent extragenital location of this disease, accounting for 8–12% of DIE [16]. The surgical approach is the main treatment option for these patients, with shaving, disc excision, and segmental bowel resection being the currently available surgical options, the latter being the most aggressive with the highest incidence of complications [18]. TVS is an established first-line imaging tool for the preoperative assessment of pelvic and deep infiltrating endometriosis [14, 19, 20]. In this retrospective study, we demonstrated the 3D TVS measurements that can influence the surgical technique, help surgeons plan and select the most appropriate surgical approach tailored to each case, potentially reducing the operative and postoperative complications. Although asymptomatic patients with rectal and rectosigmoid DIE may not need surgery, the presence of a large lesion causing luminal stenosis or evidence of disease progression on 3D TVS may prompt surgical intervention to prevent future complications [20]. High sensitivity, specificity, and accuracy were reported in all DIE locations in our series, similar to previously published results [14, 19]. Almost a quarter of cases in our series with rectal DIE had no endometriomas, which highlights the importance of a systematic ultrasound approach in all female patients with pelvic pain and the need for a meticulous search of DIE even without ovarian involvement. In our institution we are following a standardized ultrasound imaging protocol in patients with clinically suspected endometriosis in line with the International Deep Endometriosis Analysis (IDEA) group [13]. Cases treated with disc excision in our series had a mean length of 2.9 cm and a thickness of 7.8 mm, in agreement with previous investigators who concluded that conservative surgical technique should be prioritized whenever feasible with calculated cutoff values of 2 to 3 cm length and 7–9 mm thickness for nodules amenable to this surgical procedure [21]. All of our shaved nodules had a thickness ≤ 7 mm with a length ranging from 0.9 to 3.8 cm, in agreement with Malzoni et al., who concluded that shaving is sufficient for thin nodules, irrespective of their length [21]. Other investigators reported that lesions with a thickness of > 7 mm cannot be treated with shaving alone, as the chance of bowel stenosis is higher, and in that case, discoid excision or segmental bowel resection is an alternative surgical option [22]. In our study, lesions excised by segmental bowel resection had the largest size, showing a mean length of 4.5 cm, with none of the lesions < 3.5 cm. According to the European Society of Human Reproduction and Embryology guidelines state that segmental bowel resection is the optimal technique for large and symptomatic patients with rectal and rectosigmoid DIE [21]. Several studies have reported that segmental bowel resection is the optimum surgical technique for large rectal and rectosigmoid nodules [23,24,25,26]. A study by Malzoni et al. showed similar results, with none of the nodules in their series showing a length < 3.0 cm and most having a lesion length from 3 to 7 cm [27]. Our data were also in agreement with other studies, which reported that segmental bowel resection is not indicated for lesions < 3 cm, as less aggressive surgical approaches like disc excision or shaving would be sufficient in this case [21, 22]. To our knowledge, the bowel circumference calculation technique using the reconstructed axial images from 3D VCI acquisition was not previously published. We believe that the circumference involvement should be used along with length and thickness measurements to aid in surgical technique selection; our results indicate that 50% circumference involvement is the upper limit for the disc excision surgical technique, with 3 out of 4 cases undergoing segmental bowel resection having a circumference > 50%. Our results are in agreement with previous investigators who reported that lesions with a circumference > 40% show a larger depth penetration and hence a higher degree of stenosis, which necessitates a more radical surgical approach [28]. The ability of TVS to predict the true extent of rectosigmoid DIE can alleviate patients’ symptoms and help the surgeon plan and tailor the most appropriate surgical approach minimizing reported postoperative complications including anastomotic leaks, rectovaginal fistula as well as fecal incontinence [29]. The study had some limitations. Due to the retrospective design and inclusion of only surgically treated patients, selection bias toward more severe disease cannot be excluded. The study was carried out at a single tertiary institution with a relatively small sample size for individual surgical techniques. The small number of segmental resections in our series limits the robustness of ROC-derived cutoff values and may overestimate diagnostic performance. More studies with larger sample sizes carried out in multiple institutions are needed in the future to further confirm and document our findings.

TVS is an accurate imaging method for the preoperative assessment and surgical planning of rectosigmoid endometriosis. In the hands of a well-trained radiologist, TVS is a non-invasive, reproducible imaging tool for the diagnosis of bowel DIE. Our results suggest that rectal nodules ≥ 3.5 cm in length and ≥ 8 mm in thickness with a circumference > 50% may be considered for segmental resection. Lesions that are ≤ 7 mm in thickness should undergo shaving irrespective of the length, as long and thin nodules have a very low risk of stenosis. Nodules that are < 3 cm in length and 7–9 mm in thickness can go for disc excision provided that the circumference involvement is not more than 50%. We believe that segmental bowel resection can be considered for lesions that are < 3 cm in length with more than 50% circumference involvement. Data availability No datasets were generated or analysed during the current study. Abbreviations - AUC: - Area under the curve - DIE: - Deep infiltrating endometriosis - IDEA: - International deep endometriosis group - RVS: - Rectovaginal septum - TRS: - Transrectal sonography - TUI: - Tomographic ultrasound imaging - TVS: - Transvaginal sonography - USL: - Uterosacral ligament - VCI: - Volume contrast imaging

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The authors would like to acknowledge Dr. Magdy Ibrahim for providing the statistical work for this manuscript. Author information Authors and Affiliations Contributions The scientific guarantor of this study is C.N. S.M.E.: Review of literature, suggesting the idea, data collection and analysis, performing ultrasound and reporting ultrasound findings, writing the original draft, reviewing and editing the manuscript. N.A.: Data collection and analysis, performing ultrasound and reporting ultrasound findings, reviewing and editing the manuscript. C.N.: Data collection and analysis, perform the surgery and reporting surgical findings, reviewing and editing the manuscript. H.E: reviewing and editing the manuscript All authors have read and approved the manuscript. Corresponding author Ethics declarations Competing interests The authors declare no competing interests. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. About this article Cite this article El-Maadawy, S., Alaaeldin, N., Nagy, C. et al. Role of 3D transvaginal ultrasound in predicting surgical technique in patients with rectal deep infiltrating endometriosis. Egypt J Radiol Nucl Med 57, 127 (2026). https://doi.org/10.1186/s43055-026-01793-1 Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1186/s43055-026-01793-1