Rectal endometriosis: predictive MRI signs for segmental bowel resection

Objective To retrospectively determine the accuracy of MRI rectal and pararectal signs in predicting the necessity for segmental resection in the case of lesions located in the rectum.

MR images of consecutive patients treated for rectal endometriosis over a 5-year period were reviewed in consensus by two blinded readers. A systematic analysis of 7 rectal (lesion length, transverse axis, thickness and circumference, and presence of a convex base, submucosal oedema and hyperintense cystic areas) and 4 pararectal (posterior vaginal fornix, parametrial, ureteral and sacro-recto-genital septum involvements) signs was performed for each lesion. MRI results were compared to the surgical procedure performed (shaving versus segmental resection).

Among 61 patients studied, 32 received a segmental resection and 29, a shaving. Receiver operating characteristic curve analysis allowed determining cut-off values for length (≥ 32 mm), transverse axis (≥ 22 mm), thickness (≥ 14 mm) and circumference (≥ 3/8 radii). The 7 rectal signs, and only the sacro-recto-genital septum pararectal sign, were significantly associated with segmental resection in univariate analysis, nodular thickness ≥ 14 mm and circumference ≥ 3/8 radii being the most predictive signs (odds ratio 94.5 and 60.4, respectively). These 2 signs remained positively associated with segmental resection in multivariate analysis and, when combined, were predictive of segmental resection with an accuracy of 90.2%.

Assessing MRI rectal and pararectal signs may accurately predict the need for segmental resection versus a more conservative approach such as shaving for rectal lesion management. Key Points • MRI analysis of rectal endometriosis, taking into account rectal and pararectal signs, may assist surgeons in the decision-making process, in counselling patients regarding the surgical procedure and in adequately allocating resources. • Among rectal signs, nodular thickness ≥ 14 mm and a circumference ≥ 38% were the most predictive signs of segmental resection. • Among pararectal signs, only the sacro-recto-genital septum involvement was significantly associated with segmental resection. Similar content being viewed by others Abbreviations - 95% CI: - 95% confidence interval - DIE: - Deep infiltrating endometriosis - OR: - Odds ratio - PPV and NPV: - Positive and negative predictive values - Se: - Sensitivity - Sp: - Specificity - TVS: - Transvaginal sonography

Chapron C, Fauconnier A, Vieira M et al (2003) Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 18(1):157–161 Chapron C, Chopin N, Borghese B et al (2006) Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod 21(7):1839–1845 Piketty M, Chopin N, Dousset B et al (2009) Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod 24(3):602–607 Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21(3):329–339 Abo C, Moatassim S, Marty N et al (2018) Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril 109(1):172–178.e1 Donnez O, Roman H (2017) Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril 108(6):931–942 Nezhat C, Li A, Falik R et al (2018) Bowel endometriosis: diagnosis and management. Am J Obstet Gynecol 218(6):549–562 Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J (2012) Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 98(3):564–571 De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P (2011) Bowel resection for deep endometriosis: a systematic review. BJOG 118(3):285–291 Chamié LP, Blasbalg R, Pereira RMA, Warmbrand G, Serafini PC (2011) Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics 31(4):E77–E100 Bazot M, Darai E, Hourani R et al (2004) Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology 232(2):379–389 Guerriero S, Condous G, van den Bosch T et al (2016) 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 48(3):318–332 Bazot M, Bornier C, Dubernard G, Roseau G, Cortez A, Daraï E (2007) Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis. Hum Reprod 22(5):1457–1463 Rossi L, Palazzo L, Yazbeck C et al (2014) Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum? Ultrasound Obstet Gynecol 43(3):322–327 Landi S, Barbieri F, Fiaccavento A et al (2004) Preoperative double-contrast barium enema in patients with suspected intestinal endometriosis. J Am Assoc Gynecol Laparosc 11(2):223–228 Chapron C, Vieira M, Chopin N et al (2004) Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis. Ultrasound Obstet Gynecol 24(2):175–179 Nisenblat V, Bossuyt PMM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2:CD009591 Guerriero S, Saba L, Pascual MA et al (2018) Transvaginal ultrasound vs magnetic resonance imaging for diagnosing deep infiltrating endometriosis: systematic review and meta-analysis. Ultrasound Obstet Gynecol 51(5):586–595 Moura APC, Ribeiro HSAA, Bernardo WM et al (2019) Correction: Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: systematic review and meta-analysis. PLoS One 14(8):e0221499 Härmä K, Binda A, Ith M et al (2020) Cloverleaf sign in pelvic magnetic resonance imaging for deep infiltrating endometriosis: association with longer operation times, greater blood loss, and higher rates of bowel resection. Invest Radiol 55(1):53–59 Bazot M, Bharwani N, Huchon C et al (2017) European Society of Urogenital Radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 27(7):2765–2775 Perandini A, Perandini S, Montemezzi S, Bonin C, Bellini G, Bergamini V (2018) Defining probabilities of bowel resection in deep endometriosis of the rectum: prediction with preoperative magnetic resonance imaging. J Obstet Gynaecol Res 44(2):292–297 Scardapane A, Lorusso F, Francavilla M et al (2017) Magnetic resonance colonography may predict the need for bowel resection in colorectal endometriosis. Biomed Res Int 2017:5981217 Brusic A, Esler S, Churilov L et al (2019) Deep infiltrating endometriosis: can magnetic resonance imaging anticipate the need for colorectal surgeon intervention? Eur J Radiol 121:108717 D’Souza N, Balyasnikova S, Tudyka V et al (2018) Variation in landmarks for the rectum: an MRI study. Colorectal Dis 20(10):O304–O309 Darwish B, Roman H (2016) Surgical treatment of deep infiltrating rectal endometriosis: in favor of less aggressive surgery. Am J Obstet Gynecol 215(2):195–200 Meuleman C, Tomassetti C, D’Hoore A et al (2011) Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 17(3):311–326 Meuleman C, Tomassetti C, Wolthuis A et al (2014) Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg 259(3):522–531 Afors K, Centini G, Fernandes R et al (2016) Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. J Minim Invasive Gynecol 23(7):1123–1129 Roman H, Vassilieff M, Gourcerol G et al (2011) Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach. Hum Reprod 26(2):274–281 Donnez J, Squifflet J (2010) Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 25(8):1949–1958 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(6):1438–1445.e2 Darai E, Ackerman G, Bazot M, Rouzier R, Dubernard G (2007) Laparoscopic segmental colorectal resection for endometriosis: limits and complications. Surg Endosc 21(9):1572–1577 Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC (2007) Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 62(7):461–470 Clement PB (2007) The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol 14(4):241–260 Busard MPH, van der Houwen LEE, Bleeker MCG et al (2012) Deep infiltrating endometriosis of the bowel: MR imaging as a method to predict muscular invasion. Abdom Imaging 37(4):549–557 Scardapane A, Bettocchi S, Lorusso F et al (2011) Diagnosis of colorectal endometriosis: contribution of contrast enhanced MR-colonography. Eur Radiol 21(7):1553–1563 Nougaret S, Reinhold C, Mikhael HW, Rouanet P, Bibeau F, Brown G (2013) The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the “DISTANCE”? Radiology 268(2):330–344 Ito TE, Abi Khalil ED, Taffel M, Moawad GN (2017) Magnetic resonance imaging correlation to intraoperative findings of deeply infiltrative endometriosis. Fertil Steril 107(2):e11–e12 Bazot M, Jarboui L, Ballester M, Touboul C, Thomassin-Naggara I, Daraï E (2012) The value of MRI in assessing parametrial involvement in endometriosis. Hum Reprod 27(8):2352–2358 Sciot C, Buy JN (2013) Secondary Mullerian system. In: Buy JN, Ghossain M (eds) Gynecologic imaging, 1st edn. Springer, Berlin, pp 439–512 Feldman MK, VanBuren WM, Barnard H, Taffel MT, Kho RM (2020) Systematic interpretation and structured reporting for pelvic magnetic resonance imaging studies in patients with endometriosis: value added for improved patient care. Abdom Radiol (NY) 45(6):1608–1622 Bazot M, Daraï E (2018) Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertil Steril 109(3):389–397 Thornton E, Morrin MM, Yee J (2010) Current status of MR colonography. Radiographics 30(1):201–218 Abrão MS, Podgaec S, Dias JA, Averbach M, Silva LFF, Marino de Carvalho F (2008) Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease. J Minim Invasive Gynecol 15(3):280–285 Leone Roberti Maggiore U, Biscaldi E, Vellone VG, Venturini PL, Ferrero S (2017) Magnetic resonance enema vs rectal water-contrast transvaginal sonography in diagnosis of rectosigmoid endometriosis. Ultrasound Obstet Gynecol 49(4):524–532 Moawad NS, Guido R, Ramanathan R, Mansuria S, Lee T (2011) Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis. JSLS 15(3):331–338 Roman H, Bubenheim M, Huet E et al (2018) Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 33(1):47–57 Roman H, Abo C, Huet E et al (2015) Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort. Dis Colon Rectum 58(10):957–966 Ruffo G, Scopelliti F, Scioscia M, Ceccaroni M, Mainardi P, Minelli L (2010) Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases. Surg Endosc 24(1):63–67 Tosti C, Pinzauti S, Santulli P, Chapron C, Petraglia F (2015) Pathogenetic mechanisms of deep infiltrating endometriosis. Reprod Sci 22(9):1053–1059 Roman H, Darwish B, Bridoux V et al (2017) Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients. Fertil Steril 107(4):977–986.e2 Fanfani F, Fagotti A, Gagliardi ML et al (2010) Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril 94(2):444–449 Funding The authors state that this work has not received any funding. Author information Authors and Affiliations Corresponding author Ethics declarations Guarantor The scientific guarantor of this publication is Pr Pascal Rousset (MD, PhD). Conflict of interest The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. Statistics and biometry One of the authors has significant statistical expertise: Pr Jean-Christophe Lega (MD, PhD). Informed consent Written informed consent was waived by the Institutional Review Board. Ethical approval Institutional Review Board approval was obtained. Study subjects or cohorts overlap Some study subjects included between June 2012 and July 2013 in this paper have been previously reported/included in “Bowel endometriosis: preoperative diagnostic accuracy of 3.0-T MR enterography—initial results. Rousset P, Peyron N, Charlot M, Chateau F, Golfier F, Raudrant D, Cotte E, Isaac S, Réty F, Valette PJ. Radiology. 2014 Oct;273(1):117–24.” However, in this last paper, only lesions located above the recto-sigmoid junction were studied, while in the present paper, only lesions of the rectum or the recto-sigmoid junction were studied. Methodology • retrospective • diagnostic study/observational • performed at one institution Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material ESM 1 (download DOCX ) (DOCX 2.66 mb) Rights and permissions About this article Cite this article Rousset, P., Buisson, G., Lega, JC. et al. Rectal endometriosis: predictive MRI signs for segmental bowel resection. Eur Radiol 31, 884–894 (2021). https://doi.org/10.1007/s00330-020-07170-4 Received: Revised: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00330-020-07170-4