Applying a statistical method in transvaginal ultrasound training: lessons from the learning curve cumulative summation test (LC-CUSUM) for endometriosis mapping

Vered H Eisenberg, Juan L Alcazar, Juan Luis Alcázar, Nissim Arbib, Eyal Schiff, Reuven Achiron, R. Achiron, Motti Goldenberg, David Soriano
Gynecological surgery · 2017 · vol. 14(1) , pp. 19 · doi:10.1186/s10397-017-1022-4 · PMID:29046621 · W2761745543
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⚙ AI-generated summary by claude@2026-06, 2026-06-08 ⓘ

The learning curve cumulative summation test demonstrated that a sonographer trained in general gynecologic ultrasonography reached proficiency in transvaginal ultrasound mapping for deep infiltrating endometriosis after examining fewer than 50 patients.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-09 ⓘ

This retrospective study in a tertiary endometriosis referral center evaluated how many transvaginal ultrasound (TVUS) examinations an experienced gynecologic sonographer newly trained in deep infiltrating endometriosis (DIE) mapping needed to reach predefined diagnostic proficiency. Using TVUS reports and stored scan data from 94 women who subsequently underwent laparoscopy (as the reference standard), the authors calculated sensitivity, specificity, PPV, NPV, and accuracy for multiple lesion sites and applied the learning curve cumulative summation (LC-CUSUM) method to model the operator’s learning curve. The LC-CUSUM results indicated proficiency was reached after 20, 26, 32, 31, 38, and 44 examinations for detecting endometriomas, bladder nodules, vaginal nodules, pouch of Douglas obliteration, bowel nodules, and uterosacral ligament nodules, respectively. The study is limited by its single-operator, retrospective design with a moderate sample restricted to women who had surgery. This paper is centrally about endometriosis — it quantifies the learning curve for TVUS to map deep infiltrating endometriotic lesions.

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Abstract

BACKGROUND: Methods available for assessing the learning curve, such as a predefined number of procedures or direct mentoring are lacking. Our aim was to describe the use of a statistical method to identify the minimal training length of an experienced sonographer, newly trained in deep infiltrating endometriosis (DIE) mapping by evaluating the learning curve of transvaginal ultrasound (TVUS) in the preoperative assessment of endometriosis. METHODS: A retrospective study in a tertiary referral center for endometriosis. Reports and stored data from TVUS scans performed by one operator with training in general gynecological ultrasound, but not in endometriosis mapping, were analyzed retrospectively for patients who subsequently underwent laparoscopy, which served as a reference standard. The performance of TVUS was assessed for the following sites: endometriomas, bladder, vagina, pouch of Douglas, bowel and uterosacral ligaments, and correlated with laparoscopic findings. Sensitivity, specificity, PPV, NPV, and accuracy were calculated, and the operator's diagnostic performance was assessed using the learning curve cumulative summation test (LC-CUSUM). RESULTS: Data from 94 women were available for analysis. The learning curve using the LC-CUSUM graph showed that the sonographer reached the predefined level of proficiency in detecting endometriosis lesions after 20, 26, 32, 31, 38, and 44 examinations for endometriomas, bladder nodules, vaginal nodules, pouch of Douglas obliteration, bowel nodules, and uterosacral ligament nodules, respectively. CONCLUSIONS: LC-CUSUM allows monitoring of individual performance during the learning process of new methodologies. This study shows that a sonographer trained in general gynecologic ultrasonography, who devotes time to learn TVUS for DIE mapping, can achieve proficiency for diagnosing the major types of endometriotic lesions after examining less than 50 patients who subsequently undergo surgery in a training setting.

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endometriosisdie_deep_infiltrating

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