Response: Lack of preoperative predictors of surgical complications in patients undergoing endometriosis surgery may be due to lack of adequate preoperative imaging

Thank you for your interest in our study and commentary.1, 2 We applaud your work to improve the adoption of ultrasound for identifying endometriosis preoperatively. We agree that significant improvements have been made in the detection of endometriosis by ultrasound. At our institution, Dr. Beryl Benacerraf and colleagues are routinely employing ultrasound to assess for deep infiltrating endometriosis.3, 4 Unfortunately, this assessment is not employed by all local radiologists and was not available to many women in our study. We have taken the opportunity to clarify the preoperative imaging reviewed in our study. The practice is largely referral-based, with most women having undergone imaging assessment prior to presentation. Of the entire cohort, 286 (n = 286/397, 72.0%) had preoperative imaging results that were available for review (Table 1). A total of 246 women (n = 246/397, 62.0%) had preoperative ultrasound available for review. Of these women, 132 (n = 132/246, 53.7%) had suspected endometriosis by ultrasound, mostly due to the presence of a suspected endometrioma (n = 122/246, 49.6%). A smaller number of women had an endometriosis implant or nodule identified on pelvic ultrasound (n = 17/246, 6.9%). Although we do not know the radiologic criteria used in the diverse group of radiology practices represented in this cohort, when an implant or nodule was suspected, it was often characterized by an echogenic focus, sometimes with documentation of adherence to adjacent structures. We agree that if a more thorough assessment of the cul-de-sacs were undertaken, then more women would have been identified as having endometriosis preoperatively. This, in turn, could aid in the prediction of perioperative complications. Interestingly, our study did not find that intraoperative identification of advanced endometriosis predicted perioperative complications. This is likely influenced by the expertise of the surgeons included, all of whom completed a fellowship in Minimally Invasive Gynecologic Surgery and frequently perform complex endometriosis surgery.