Deep endometriosis: evaluation of ENZIAN and #ENZIAN classification systems by MRI compared with surgery-a meta-analysis

Yasmin Mohamed, Yusra Mohamed, Sabrine Q Kol, Jaap Stoker, Shandra Bipat
European radiology · 2025 · vol. 36(6) , pp. 4489–4502 · doi:10.1007/s00330-025-12154-3 · PMID:41317188 · W4416810975
meta-analysis OA: closed CC0
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⚙ AI-generated summary by claude@2026-06+body, 2026-06-08 ⓘ

MRI-based ENZIAN classification demonstrated high diagnostic values for ovarian, tubo-ovarian, vaginal, rectovaginal, uterosacral ligament, and rectal compartments in deep endometriosis assessment.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-08 ⓘ

This meta-analysis evaluated the reproducibility and diagnostic accuracy of MRI for assessing deep endometriosis using ENZIAN and #ENZIAN classification systems, comparing MRI findings with surgery-based reference standards across 12 studies (1024 patients). Across multiple pelvic compartments, MRI-based #ENZIAN showed substantial to excellent interobserver/intraobserver reliability and high diagnostic values for the ovary, tubo-ovarian condition, vaginal/rectovaginal space, uterosacral ligaments, and rectosigmoid, including high sensitivity/specificity for O and T and moderately lower but still high sensitivity for A, B, and C. In contrast, sensitivity for adenomyosis-related compartment FA and bladder and intestinal compartments (FB and FI) was low, and data for peritoneum (P), ureter (FU), and other (FO) compartments were insufficient for pooling. This paper is centrally about endometriosis — it quantifies MRI reliability and diagnostic accuracy for ENZIAN/#ENZIAN classification in deep endometriosis.

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Abstract

OBJECTIVE: To assess the reproducibility and the diagnostic accuracy of MRI for the assessment of (#)ENZIAN classification in patients with deep endometriosis by means of a meta-analysis. MATERIALS AND METHODS: MEDLINE and EMBASE databases were searched for relevant articles from January 1, 2005, to January 1, 2025. Data on MRI reproducibility (interobserver/intraobserver kappa) were extracted for P (peritoneum), O (ovary), T (tubo-ovarian condition), A (vagina/rectovaginal space), B (utero-sacral ligaments), C (rectum/sigmoid colon), FA (F adenomyosis), FB (F bladder), FU (F ureter), FI (F intestinum), and FO (F other). Pooled sensitivity, specificity, PPV, and NPV were calculated for each compartment. RESULTS: Twelve articles (1024 patients) were included, of which 7 used ENZIAN and 5 used #ENZIAN. MRI-based (#)ENZIAN showed high reliability for O, A, B, and C, with substantial or excellent agreement in most studies. MRI-based (#)ENZIAN showed high diagnostic values for O, T, A, B, and C. Sensitivity and specificity for O were 97.5% and 96.4% and for T, 94.1% and 89.1%, respectively. Sensitivity values for A, B, and C were slightly lower, but remained high at 76.1%, 83.4%, and 79.1% respectively, and specificity values were high at 92.4%, 87.8%, and 94.8%. Sensitivity values for FA, FB, and FI were low, with values of 64.6%, 56.9%, and 66.8%. Data for P, FU, and FO were insufficient and could not be pooled. CONCLUSION: MRI-based (#)ENZIAN showed high reliability for compartments O, T, A, B, and C. Data for other compartments were either insufficient or the diagnostic accuracy was low. KEY POINTS: Question What is the diagnostic value of MRI in the assessment of (#) ENZIAN classification in patients with deep endometriosis? Findings MRI-based(#)ENZIAN showed high diagnostic values for compartments O, T, A, B, and C. Data on the remaining compartments were insufficient, or the diagnostic accuracy was low. Clinical relevance MRI-based (#) ENZIAN can be used for assessing endometriosis located at the ovaries, tubal ovarian condition, vaginal-rectovaginal space, utero-sacral ligaments, and rectosigmoid. For other compartments, more data are needed and clear definitions might also improve the role of MRI.

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Outcome instruments

rASRM Enzian

Condition tags

endometriosis

MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging Magnetic Resonance Imaging

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

References (38)

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