Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis

Purpose The aim of this study is to investigate the correlation between the magnetic resonance imaging (MRI) and intraoperative findings of deep infiltrating endometriosis using the #ENZIAN score.

This retrospective study included 64 patients who underwent surgery for deep infiltrating endometriosis between January 2017 and August 2020. Preoperative abdominopelvic MRI assessment was evaluated and scored using the #ENZIAN classification. Operative scores were considered the gold standard, and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of MRI for each category were calculated.

MRI has higher sensitivity and specificity in showing the lesions of the compartments O (ovarian lesions), A (rectovaginal septum and posterior vaginal fornix), and B (uterosacral ligaments and parametrium) (100–100%, 100–100%, and 97–100%, respectively, p < 0.001) compared to the other compartments. The lowest sensitivity, specificity, accuracy, and PPV of the MRI was found in compartment P (14%, 76%, 70%, and 7%, respectively).

We demonstrated that the #ENZIAN classification in MRI reports has significant sensitivity and specificity in compartments A, B (uterosacral ligaments and parametrium), and O. Furthermore, the determination of peritoneal lesions via MRI is inadequate. Similar content being viewed by others

Foti PV, Farina R, Palmucci S, Vizzini IAA, Libertini N, Coronella M, Spadola S, Caltabiano R, Iraci M, Basile A, Milone P, Cianci A, Ettorre GC (2018) Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights Imaging 9(2):149–172 Chamié LP, Blasbalg R, Pereira RM, Warmbrand G, Serafini PC (2011) Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics 31(4):E77-100 Ballard K, Lowton K, Wright J (2006) What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of endometriosis. Fertil Steril 86:1296–1301 (PubMed: 17070183) Hadfield R, Mardon H, Barlow D, Kennedy S (1996) Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. Hum Reprod 11:878–880 (PubMed: 8671344) Nnoaham KE, Hummelshoj L, Webster P, d’Hooghe T, de Cicco NF, de Cicco NC, Jenkinson C, Kennedy SH, Zondervan KT (2011) World Endometriosis Research Foundation Global Study of Women’s Health consortium. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 96(2):366–3738 Medeiros LR, Rosa MI, Silva BR, Reis ME, Simon CS, Dondossola ER, da Cunha Filho JS (2015) Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet 291(3):611–621 Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, Bush D, Kiesel L, Tamimi R, Sharpe-Timms KL, Rombauts L, Giudice LC (2017) World Endometriosis Society Sao Paulo Consortium. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 32(2):315–324 Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, Krentel H, Janschek E, Exacoustos C, Malzoni M, Mueller M, Roman H, Condous G, Forman A, Jansen FW, Bokor A, Simedrea V, Hudelist G (2021) The #Enzian classification: a comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 100(7):1165–1175 Bazot M, Bharwani N, Huchon C, Kinkel K, Cunha TM, Guerra A et al (2017) European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 27(7):2765–2775. https://doi.org/10.1007/s00330-016-4673-z (Epub2016/12/05, PubMedPMID:27921160;PubMedCentralPMCID:PMCPMC5486785) Burla L, Scheiner D, Samartzis EP, Seidel S, Eberhard M, Fink D, Boss A, Imesch P (2019) The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis. Arch Gynecol Obstet 300(1):109–116 Burla L, Scheiner D, Hötker AM, Meier A, Fink D, Boss A, Imesch P (2021) Structured manual for MRI assessment of deep infiltrating endometriosis using the ENZIAN classification. Arch Gynecol Obstet 303(3):751–757 Di Paola V, Manfredi R, Castelli F, Negrelli R, Mehrabi S, Pozzi Mucelli R (2015) Detection and localization of deep endometriosis by means of MRI and correlation with the ENZIAN score. Eur J Radiol 84(4):568–574 Ruffo G, Sartori A, Crippa S et al (2012) Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results. Surg Endosc 26:1035–1040 Maytham GD, Dowson HM, Levy B et al (2010) Laparoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature. Colorectal Dis 12:1105–1112 Koh CE, Juszczyk K, Cooper MJ et al (2012) Management of deeply infiltrating endometriosis involving the rectum. Dis Colon Rectum 55:925–931 Tomassetti C, Meuleman C, Vanacker B et al (2009) Lower limb compartment syndrome as a complication of laparoscopic laser surgery for severe endometriosis. Fertil Steril 92:2.038E12-2.038E15 Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2(2):CD009591 Andres MP, Borrelli GM, Abrão MS (2018) Endometriosis classification according to pain symptoms: can the ASRM classification be improved? Best Pract Res Clin Obstet Gynaecol 51:111–118 Canis M, Donnez JG, Guzick DS, Halme JK, Rock JA, Schenken RS, Vernon MW (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67(5):817–821 Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F, Crosignani PG (1996) Endometriosis and pelvic pain: relation to disease stage and localization. Fertil Steril 65(2):299–304 Vercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, Crosignani PG (2006) Reproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system. Hum Reprod 21(10):2679–2685 Guzick DS, Silliman NP, Adamson GD, Buttram VC, Canis M, Malinak LR et al (1997) Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine’s revised classification of endometriosis. Fertil Steril 67(5):822–829 Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG (2007) Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients. Hum Reprod 22(1):266–271 Haas D, Oppelt P, Shebl O, Shamiyeh A, Schimetta W, Mayer R (2013) Enzian classification: does it correlate with clinical symptoms and the rASRM score? Acta Obstet Gynecol Scand 92:562–566 Mutuku T (2016) Prä-operative Abschätzung einer tief infiltrierenden Darmendometriose mittels Untersuchungsbefund in der ENZIAN-Klassifikation und der Symptomatik sowie Vergleich mit dem intra- operativen ENZIAN-Befund [The assessment of deep infiltrating endometriosis according to the preoperative investigation and symptoms in comparison to intraoperative findings with the ENZIAN- Classification]. MD Thesis, Universität Ulm. https://doi.org/10.18725/OPARU-3751 Haas D, Chvatal R, Habelsberger A et al (2013) Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification. Eur J Obstet Gynecol Reprod Biol 166:99–103 Roman H, Moatassim-Drissa S, Marty N et al (2016) Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril 106:1438–45.e2 Alves J, Puga M, Fernandes R, Pinton A, Miranda I, Kovoor E, Wattiez A (2017) Laparoscopic management of ureteral endometriosis and hydronephrosis associated with endometriosis. J Minim Invasive Gynecol 24(3):466–472 Kiesel L, Sourouni M (2019) Diagnosis of endometriosis in the 21st century. Climacteric 22(3):296–302 Novellas S, Chassang M, Delotte J, Toullalan O, Chevallier A, Bouaziz J, Chevallier P (2011) MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. AJR Am J Roentgenol 196:1206–1213. https://doi.org/10.2214/AJR.10.4877 Funding The authors have not disclosed any funding. Author information Authors and Affiliations Contributions AFT contributed to concept, study design and manuscript writing. DEI contributed to data collecting and manuscript writing, AAG evaluate the MRI and collected the data, and CK contributed to concept, study design. Data analysing and manuscript editing. All authors read and approved the submitted manuscript. Corresponding author Ethics declarations Conflict of interest The authors declare that they have no conflict of interest. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions About this article Cite this article Fendal Tunca, A., Iliman, D.E., Akdogan Gemici, A. et al. Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis. Arch Gynecol Obstet 307, 215–220 (2023). https://doi.org/10.1007/s00404-022-06451-1 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00404-022-06451-1