Diagnostic MRI for deep pelvic endometriosis: towards a standardized protocol?

Objectives To assess the diagnostic efficacy of an MRI protocol and patient preparation in detecting deep pelvic endometriosis (DPE).

The cohort is from the ENDOVALIRM database, a multicentric national retrospective study involving women who underwent MRI followed by pelvic surgery for endometriosis (reference standard). Two senior radiologists independently analyzed MRI findings using the deep pelvic endometriosis index (dPEI) to determine lesion locations. The study evaluated the impact of bowel preparation, vaginal and rectal opacification, MRI unit type (1.5-T or 3-T), additional sequences (thin slice T2W or 3DT2W), and gadolinium injection on reader performance for diagnosing DPE locations. Fisher’s exact test assessed differences in diagnostic accuracy based on patient preparation and MRI parameters.

The final cohort comprised 571 women with a mean age of 33.3 years (± 6.6 SD). MRI with bowel preparation outperformed MRI without bowel preparation in identifying torus/uterosacral ligament (USL) locations (p < 0.0001) and rectosigmoid nodules (p = 0.01). MRI without vaginal opacification diagnosed 94.1% (301/320) of torus/USL locations, surpassing MR with vaginal opacification, which diagnosed 85% (221/260) (p < 0.001). No significant differences related to bowel preparation or vaginal opacification were observed for other DPE locations. Rectal opacification did not affect diagnostic accuracy in the overall population, except in patients without bowel preparation, where performance improved (p = 0.04). There were no differences in diagnostic accuracy regarding MRI unit type (1.5-T/3-T), presence of additional sequences, or gadolinium injection for any endometriotic locations.

Bowel preparation prior to MRI examination is preferable to rectal or vaginal opacification for diagnosing deep endometriosis pelvic lesions. Clinical relevance statement Accurate diagnosis and staging of DPE are essential for effective treatment planning. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols. Optimizing MRI protocols for diagnostic performance with appropriate opacification techniques will help diagnose deep endometriosis more accurately. Key Points - Evaluating deep endometriosis in collapsible organs such as the vagina and rectum is difficult. - Bowel preparation and an absence of vaginal opacification were found to be diagnostically beneficial. - Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols. Similar content being viewed by others Change history 10 October 2024 A Correction to this paper has been published: https://doi.org/10.1007/s00330-024-11098-4 Abbreviations - DE: - Deep endometriosis - DPE: - Deep pelvic endometriosis - dPEI: - Deep pelvic endometriosis index - ESUR: - European Society of Urogenital Radiology - MRI: - Magnetic resonance imaging - USL: - Uterosacral ligament

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President of the French women’s imaging society (SIFEM). Pascal Rousset declares, a member of the advisory board for Ziwig. The other authors do not declare any other financial relationship or disclosure. Statistics and biometry Not applicable. Informed consent Written informed consent was waived by the Institutional Review Board. Ethical approval Institutional Review Board approval was obtained (Hospice Civil Lyon, CNIL 20_5220). Study subjects or cohorts overlap All the patients come from the cohort ENDOVALIRM [9]: Thomassin-Naggara I, Monroc M, Chauveau B, et al (2023) Multicenter External Validation of the dPEI Magnetic Resonance Imaging Score. JAMA Netw Open 6:e2311686. https://doi.org/10.1001/jamanetworkopen.2023.11686. However, the features studied were not analyzed. A secondary reading was specifically performed for this study and has not already been published. Methodology - Retrospective - Observational - Multicenter study Additional information Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The original online version of this article was revised: In this article the name of author Léo Razakamanantsoa was incorrectly written as Léo Razakamantsoa. Supplementary information Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Thomassin-Naggara, I., Zoua, C.S., Bazot, M. et al. Diagnostic MRI for deep pelvic endometriosis: towards a standardized protocol?. Eur Radiol 34, 7705–7715 (2024). https://doi.org/10.1007/s00330-024-10842-0 Received: Revised: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00330-024-10842-0