Why create a new protocol or a new consensus in the ultrasound diagnosis of endometriosis?

Why create a new protocol or a new consensus in the ultrasound diagnosis of endometriosis? Abstract Linked article: This Correspondence comments on Deslandes and Leonardi. Click here to view the article. We read with interest the manuscript entitled: ‘Proposed simplified protocol for initial assessment of endometriosis with transvaginal ultrasound’ by Deslandes and Leonardi1. We appreciate their enthusiasm for raising awareness of endometriosis when performing standard ultrasound. However, we have major concerns. We do not understand why they consider that the consensus proposed by the International Deep Endometriosis (IDEA) group is ‘only’ to be used by experts or in specialist centers2. On the contrary, the IDEA consensus, cited so far in more than 500 articles, suggests a systematic approach for endometriosis evaluation, based on four steps (uterine and adnexal assessment; presence of soft markers; sliding sign; and assessment of deep endometriosis nodules in anterior and posterior compartments), as well as, added recently, evaluation of the parametrium; steps that can be used by both expert and non-expert examiners. In fact, Deslandes and Leonardi1 introduce the concept of ‘simplified ultrasound’, adding to a standard ultrasound examination evaluation of the uterosacral ligaments (USLs), the upper rectum and the uterine sliding sign for obliteration of the pouch of Douglas, but missing entirely the anterior compartment, parametrium and most of the posterior compartment. This represents a difficulty for sonographers, as, without evidence or suggested learning curves to look for these lesions, many will be missed or misclassified, including the most common and difficult to assess, those of the USLs3. In parallel, a recently published article by Young et al.4 tries to introduce another ‘augmented’ ultrasound protocol, but lacks a systematic approach for scanning and fails to describe how to interpret normal findings, identify lesions and measure them. This omission could lead to inaccurate and subjective evaluations. Of particular concern, the articles by Deslandes and Leonardi1 and Young et al.4 do not consider as mandatory the complete evaluation of areas with a high prevalence of lesions, such as those involving the rectosigmoid, a region in which it has been demonstrated that ultrasound has very high accuracy3. Deslandes and Leonardi1 suggest that the length of the examination could be a potential reason that prevents us from doing a comprehensive evaluation. However, they do not provide an appropriate time for the comprehensive approach; nor is there any literature consistent with these assumptions. In addition, the consensus by Young et al.4 suggests that a routine ultrasound examination takes up to 30–45 min, with the addition of an ‘augmented’ evaluation requiring only 2–5 min. We think this is an overestimation of the examination time required for a routine evaluation and would therefore be sufficient to incorporate the four steps of the IDEA protocol for a complete examination, thereby improving the management of the patient and decreasing the time to diagnosis, by avoiding the expected referral for yet another ultrasound evaluation. The introduction of an opinion-based article for clinical implementation without supporting prospective studies prevents its application and reproduction in clinical practice. Moreover, we think these proposals could be detrimental to patients affected by endometriosis. Finally, we would like to stress that the IDEA protocol is intended not only for experts; it also represents the common language for any further development. Some studies have demonstrated that the learning curve for endometriosis recognition is improved by using the IDEA structured approach5. Therefore, we suggest that we focus all of our efforts on operator training using an established approach, instead of introducing new protocols for which there is no supporting evidence, so that patients can finally be provided with an integral evaluation in a single exam. DATA AVAILABILITY STATEMENT Data sharing is not applicable to this article as no new data were created or analyzed in this study.