The use of MRI to plan for therapeutic laparoscopy at the time of endometriosis diagnosis

Currently, we have collected data on 143 patients. No patients received a diagnostic laparoscopy. All patients received a therapeutic laparoscopy at the time of diagnosis. In total, 139 patients had complete surgical records, of which 35 had negative and 95 had positive therapeutic laparoscopies. From our sample, 90 patients had recorded MRI and laparoscopy data. MRI scans were interpreted by clinicians with specialist endometriosis experience. Overall, MRI identified endometriosis with a sensitivity of 92%, specificity of 42%, positive-predictive value (PPV) of 89% and negative predictive value (NPV) of 50%. This suggests that MRI is better for ruling out endometriosis and a positive MRI is likely to see a positive laparoscopy. A similar trend is seen for identifying superficial and deep disease ( Table 2 ). The converse was true when examining the #ENZIAN components, where MRI tends to have a higher specificity and NPV ( Table 2 ). This suggests that when examining #ENZIAN components, MRI is a useful tool for ruling in endometriosis and that a negative laparoscopy is likely to follow a negative MRI. We had insufficient data to interpret the MRI findings of disease severity for each #ENZIAN component. Table 2 MRI comparison to gold standard of laparoscopy. MRI comparison to gold standard of laparoscopy.

This is a retrospective cohort study. We sampled 372 patients who received laparoscopy at Cambridge Endometriosis Endoscopic Surgery Unit (CEES-U) from its establishment on 1 December 2017 to the beginning of this study on 31 May 2021. The intervention investigated is diagnostic laparoscopy. Our comparison is patients who received a therapeutic laparoscopy at the time of diagnosis, thus not undergoing a diagnostic laparoscopy. Our outcome of interest was whether pre-operative transvaginal ultrasound (TVUS) and MRI in our comparison group was representative of disease at laparoscopy. We collected data from patient records using EPIC, CEES-U's electronic record system. Findings of endometriosis at TVUS, MRI and surgery were recorded using #ENZIAN scoring. 3 #ENZIAN allows binary scoring of endometriosis according to location ( Table 1 ). Table 1 #ENZIAN components explained. Endometriosis is classified as deep if any of A, B, C or F are present #ENZIAN component abbreviation #ENZIAN component What it includes P Peritoneum All superficial peritoneal foci located in pelvis and abdomen above pelvic rim that are not considered deep endometriosis. O (right and left) Ovary (right and left) Right and left scored separately. All endometriomas and infiltrating ovarian surface foci (diameter ≥5mm). T (right and left) Tubo-ovarian condition (right and left) Right and left scored separately. Mobility of ovaries and tubes due to adhesions. A Compartment A Vagina, retro-cervical area, rectovaginal space. B (right and left) Compartment B Right and left scored separately. Uterosacral ligament, cardinal ligaments, pelvic side wall. C Compartment C Rectum (lesions ≥16cm from anal verge). F 'Far away’ Includes: adenomyosis, intestinum, ureter, any remaining locations. #ENZIAN components explained. Endometriosis is classified as deep if any of A, B, C or F are present

We recommend that clinicians use MRI to identify endometriosis and record the specific locations according to #ENZIAN scoring. This maximises the value of MRI to ensure interpretation is increasingly likely to be representative of disease state at laparoscopy. We believe that this evidence suggests that MRI, combined with pre-operative history, examination and TVUS, may be sufficient to facilitate therapeutic laparoscopies at the time of diagnosis, removing the surgical risk associated with an additional diagnostic laparoscopy. We are currently collecting the remaining patient data and will conduct further analysis on the utility of both MRI and TVUS.

Endometriosis is estimated to affect ∼6–10% of reproductive age women, and 30–50% of patients with infertility and/or pain. 1 , 2 The National Institute for Health and Care Excellence recommends, for most presentations, a diagnostic laparoscopy is done prior to a therapeutic laparoscopy. Diagnostic and therapeutic laparoscopies are defined as laparoscopies with the intention to diagnose or treat respectively. A therapeutic laparoscopy can be either negative, where endometriosis is not present, or positive, where endometriosis is present and is treated. We hypothesise that patients with endometriosis should receive a therapeutic laparoscopy only, being diagnosed and treated in a single laparoscopy.