The Role of MRI in Diagnosis and Pre-Surgical Mapping of Endometriosis

Endometriosis is a chronic multisystem disease caused by the presence of endometrium-like tissue outside the endometrial canal, inciting inflammation and fibrosis. Transvaginal ultrasound (TVUS) and MRI have replaced diagnostic laparoscopy as the noninvasive imaging modalities of choice for diagnosis and pre-surgical planning. Advanced disease in the pelvis can distort/obliterate anatomic planes and obscure the extent of pelvic organ involvement at laparoscopy. Unlike laparoscopy, MRI is not limited by anatomic distortion and provides accurate multi-compartment assessment of deep pelvic endometriosis involving the uterus and its ligaments, adnexa, bowel, distal ureters, urinary bladder, and pelvic nerves. Additionally, MRI can help detect extra-pelvic organ involvement in the same study. Use of a dedicated MRI protocol and structured reporting template improves multidisciplinary communication and provides a pre-surgical road map; helps patient counseling as well as assessing the need for additional intraoperative organ-specific expertise such as colorectal surgery or urology. Knowledge of MRI and laparoscopic correlation enhances recognition of the key MRI findings to include in the report for optimizing surgical outcomes. This article focuses on the role of MRI in the diagnosis and pre-surgical mapping of pelvic endometriosis, with correlation to laparoscopic findings. Evidence level: 1. Technical efficacy: 5. Conflicts of Interest The authors declare no conflicts of interest. Supporting Information | Filename | Description | |---|---| | jmri70039-sup-0001-supinfo.zipZip archive, 24.1 MB | Figure SM1. 40-year-old female with a large endometrioma located in the pouch of Douglas. Note the focal T2-hypointense nodule in the dependent portion of the endometrioma, representing the T2-dark spot sign (white arrow). Figure SM2. 35-year-old female with severe dysmenorrhea demonstrates right uterosacral ligament thickening (black arrowhead); retrocervical deep implants (white arrow) and left round ligament asymmetric thickening with active glandular implants (arrowheads). This patient was incidentally found to have a unicollis uterus with a right rudimentary horn (white asterisk). These MRI findings allowed accurate pre-surgical planning and patient counseling for symptom relief as well as future fertility considerations. SM3. 41-year-old female with pelvic MRI demonstration of severe posterior compartment deep endometriosis. Accompanying videos represent cine images from axial T1- and T2-weighted MRI sequences in this patient demonstrating the sigmoid colon coursing over and adherent to the left endometrioma; a left hematosalpinx located in the posterior cul-de-sac as well as additional hemorrhagic implants in the left parametrium. Pre (SM3a) and Intraoperative (SM3b) laparoscopic images correlated well with the pre-surgical MRI allowing appropriate anticipation of surgical complexity and optimal disease resection. Figure SM3a. Endometriosis atop the uterus (dotted circle) with partial obliteration of the pelvis and cul-de-sac due to dense sigmoid adhesions covering the left adnexa (left fallopian and ovary). Figure SM3b. Pelvic view during laparoscopy following extensive lysis of adhesions to mobilize the sigmoid colon off from the left adnexa. Left fallopian tube (dotted circle) filled with blood consistent with a hematosalpinx. Left ovary (solid circle) enlarged due to a 5-cm endometrioma. Figure SM4. Template for Structured Reporting of Pelvic MRI in suspected Endometriosis. | Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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