Accuracy of laparoscopic diagnosis of endometriosis

Mettler L; Schollmeyer T; Lehmann-Willenbrock E; Schüppler U; Schmutzler A; Shukla D; Zavala A; A Lewin

Endometriosis · Diagnosis

Accuracy of laparoscopic diagnosis of endometriosis

Mettler L, Schollmeyer T, Lehmann-Willenbrock E, Schüppler U, Schmutzler A, Shukla D, Zavala A, Lewin A

Published May 2, 2003 JSLS : Journal of the Society of Laparoendoscopic Surgeons, 7(1), 15-18

PMID 12722993

Read our synopsis

RRM Academy Synopsis

Biopsy confirmed visual endometriosis diagnosis at 53.8% of sites

Biopsy confirmed the surgeons' visual diagnosis at 142 of 264 suspected sites (53.8%) in a 2003 case series of 164 patients at one German university department (Kiel). Red lesions held up best. White lesions held up least.

Key Findings

Biopsy found endometriosis in 138 of 164 patients (84.1%). In 26 patients (15.9%), biopsy showed no endometriosis.
Surgeons suspected endometriosis at 264 sites. Tissue examination confirmed it at 142 of them (53.8%).
Lesion color mattered. All 82 biopsied red lesions were endometriosis. Black lesions were endometriosis 92% of the time, and white lesions 31%.
Confirmation was 9 of 9 on the parietal peritoneum of the pelvis, 8 of 12 in the ovarian fossa and 83 of 138 (60.1%) on the uterosacral ligaments and posterior broad ligament.
Confirmation was lower on the ovarian surface (37 of 77, 48%), bowel serosa (2 of 5, 40%) and vesicouterine fold (3 of 23, 13%).

Interpretation

The study is a case series from the University of Kiel, using registry data from 1998 to 2000. Surgeons took biopsies from lesions they suspected. The work compares suspicion with tissue findings. Deep infiltrating lesions and microscopic implants were outside its scope. The authors note that magnification may add to overdiagnosis. They also note that some fibrous lesions may come from earlier endometriotic damage. The authors conclude that tissue confirmation should remain the first step in diagnosing suspected endometriosis at laparoscopy.

RRM Context

Restorative reproductive medicine puts evaluation before treatment, and these figures show why evaluation needs tissue. In these cases, the authors aimed to excise all visible red, black or white lesions and confirm them under the microscope. Excision with pathology gives a tissue diagnosis from the lesions removed. The authors warn that diagnosis without tissue proof may lead to unnecessary, prolonged medical treatment. Of 164 patients, 26 had no endometriosis on biopsy.

Our editorial summary of this paper, not the article's abstract.

Abstract

Background and Objectives

Laparoscopy is the standard method to visually identify endometriotic lesions under magnification within and outside the minor pelvis. The aim of this study was to analyze the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically.

Method

Presumed endometriotic sites were observed in 164 patients operated on under the clinical suspicion of endometriosis. Targeted biopsies were performed for histologic corroboration, comparing the laparoscopic findings and diagnosis to the histological results.

Result

The histological reports of the biopsies confirmed the presence of endometriosis in 138 patients (84.1%), but in 26 patients (15.9%), no evidence of endometriosis was observed. 100% of "red" lesions, 92% of "black" lesions, and 31% of "white" lesions turned out to be endometriosis. Of the 264 various suspected endometriotic sites observed, 142 (53.8%) were confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 9/9 cases (100%); the ovarian fossa, confirmed in 8/12 cases (66.7%); and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 83/138 cases (60.1%). As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesicouterine fold of the peritoneum were 48%, 40%, and 13%, respectively.

Conclusion

Endometriosis has a multiple appearance, and the lesions may be confused with nonendometriotic lesions. It is clear that a nonhistology-based diagnosis may lead to unnecessary prolonged medical treatment and operations and may delay the proper treatment measures from being applied. Therefore, a meticulous histological confirmation should still be the first step in the laparoscopic diagnosis and treatment of suspected endometriosis.

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Is the obstetric outcome of in vitro fertilized singleton gestations different from natural ones? A controlled study

Reubinoff BE et al., 1997 Fertil Steril

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Correlation between the zona-free hamster egg sperm penetration assay and human in vitro fertilization

Margalioth EJ et al., 1986 Fertil Steril

The association between in vitro fertilization (IVF) and the zona-free hamster egg sperm penetration assay (SPA) was studied in 134 couples. The indications for IVF were tubal disease in 82 couples, unexplained infertility in 23, male infertility in 10, and combined mechanical and male factors in 19. In general, a positive SPA was a good predictor of subsequent IVF (91 of 107 couples). Specificity (number of couples with fertilization in vitro divided by the number of couples with a positive SPA times 100) was 94% for tubal infertility, 76% for unexplained infertility, and 46% for male infertility. A negative SPA predicted an overall fertilization failure of 78% (21 of 27 couples). Sensitivity of the test (number of couples with IVF failure divided by the number of couples with a negative SPA times 100) was 100% for tubal and unexplained infertility but only 63% for male infertility. The high predictive value of the SPA for subsequent IVF outcome in tubal infertility and unexplained infertility warrants its routine use for prescreening in IVF programs. Because of the lack of association between SPA and IVF in oligoasthenospermia, the bioassay should not be relied upon for predicting IVF outcome in male subfertility. The overall high association between the animal model and human IVF reinforces the use of the SPA for both basic research and clinical decision-making.

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Diagnosis · Staging and Classification

The diagnostic dilemma of minimal and mild endometriosis under routine conditions

Buchweitz O et al., 2003 J Am Assoc Gynecol Laparosc

To evaluate the reliability of diagnosing minimal and mild endometriosis under routine conditions, and to determine to what extent disease activity is taken into account. Retrospective analysis (Canadian Task Force classification II-2). University teaching hospital. Laparoscopy. One hundred eighteen consecutive women with minimal and mild endometriosis undergoing routine surgery between 1994 and 1999. MAIN Analytic parameters were the total number of endometriotic lesions; intraoperative description of pigmented, nonpigmented, and nondefined lesions; and number of extirpated lesions and histologic detection rate. In 118 patients, 311 suspected endometriotic lesions were documented. Nonpigmented lesions were reported in only 27% of women. In 51% of surgical reports no importance was attached to disease morphology or activity. Only 1.2 biopsies/patient were taken. The histologic detection rate was 56%. In 49 patients the assumed intraoperative diagnosis was confirmed by histologic examination. Intraoperative description of endometriotic lesions is inadequate. Little attention is paid to the activity of the illness. There is room for improvement in the number of excisions and histologic detection, and an attempt should be made to find a way out of this diagnostic dilemma.

Diagnosis · Imaging

'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis

Mak J et al., 2022 Reprod Fertil Free full text on PubMed Central

Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.

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Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis

Chapron C et al., 2002 J Am Assoc Gynecol Laparosc

To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). Retrospective analysis (Canadian Task Force classification II-2). University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. MAIN Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term "deep endometriosis infiltrating the rectovaginal septum" is generally incorrect in the true anatomic sense.

Measurement and Statistics · Statistical Methods

Endometriosis diagnosis and staging by operating surgeon and expert review using multiple diagnostic tools: an inter-rater agreement study

Schliep KC et al., 2017 BJOG Free full text on PubMed Central

To determine agreement on endometriosis diagnosis between real-time laparoscopy and subsequent expert review of digital images, operative reports, magnetic resonance imaging (MRI), and histopathology, viewed sequentially. Inter-rater agreement study. Five urban surgical centres. Population: Women, aged 18-44 years, who underwent a laparoscopy regardless of clinical indication. A random sample of 105 women with and 43 women without a postoperative endometriosis diagnosis was obtained from the ENDO study. Laparoscopies were diagnosed, digitally recorded, and reassessed. Inter-observer agreement of endometriosis diagnosis and staging according to the revised American Society for Reproductive Medicine criteria. Prevalence and bias-adjusted kappa values (κ) were calculated for diagnosis, and weighted κ values were calculated for staging. Surgeons and expert reviewers had substantial agreement on diagnosis and staging after viewing digital images (n = 148; mean κ = 0.67, range 0.61-0.69; mean κ = 0.64, range 0.53-0.78, respectively) and after additionally viewing operative reports (n = 148; mean κ = 0.88, range 0.85-0.89; mean κ = 0.85, range 0.84-0.86, respectively). Although additionally viewing MRI findings (n = 36) did not greatly impact agreement, agreement substantially decreased after viewing histological findings (n = 67), with expert reviewers changing their assessment from a positive to a negative diagnosis in up to 20% of cases. Although these findings suggest that misclassification bias in the diagnosis or staging of endometriosis via visualised disease is minimal, they should alert gynaecologists who review operative images in order to make decisions on endometriosis treatment that operative reports/drawings and histopathology, but not necessarily MRI, will improve their ability to make sound judgments. Tweetable Abstract: Endometriosis diagnosis and staging agreement between expert reviewers and operating surgeons was substantial.

Endometriosis › Diagnosis › Staging and Classification · General Gynecology › Clinical Practice › Practice Patterns

PMID 12722993 12722993 Mettler et al. 2003, Mettler 2003

Cite this article

Mettler, L., Schollmeyer, T., Lehmann-Willenbrock, E., Schüppler, U., Schmutzler, A., Shukla, D., Zavala, A., & Lewin, A. (2003). Accuracy of laparoscopic diagnosis of endometriosis. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 7(1), 15-18.

Keywords

Endometriosis/diagnosis/surgery, Female, Humans, Laparoscopy/methods, Neoplasm Staging, Uterine Diseases/diagnosis/surgery