Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy.
Department of Health Promotion, Mother and Child Care, Internal Medicine, and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.
Gynecol Obstet Invest. 2024;89(2):111-119. doi: 10.1159/000535940. Epub 2024 Feb 20.
The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria.
A diagnostic accuracy study was employed based on a prospective observational design.
All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered.
The study was conducted at endometriosis referral hospitals.
We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard.
In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70-96.92%, 95% CI) for the right side and 87.91% (79.40-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90-98.84%, 95% CI) and 96.22% (94.04-97.74%, 95% CI), respectively.
The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives.
TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.
本研究旨在评估经阴道超声（TVS）对侧方宫旁子宫内膜异位症（PE）的诊断准确性，该方法采用系统方法评估侧方宫旁。
本研究采用前瞻性观察性设计。
所有 2016 年 1 月至 2020 年 12 月因子宫内膜异位症接受腹腔镜手术的连续患者均被认为符合条件。
研究在子宫内膜异位症转诊医院进行。
我们前瞻性收集了所有 2016 年 1 月至 2020 年 12 月因子宫内膜异位症接受腹腔镜手术的连续患者的临床、影像学和手术数据。采用一种标准化技术，根据特定的解剖学标志对侧方宫旁进行系统评估，用于 TVS。使用术中及病理诊断为 PE 的诊断标准来评估 TVS 对 PE 的诊断准确性。
在 476 例接受手术的患者中，114 例（23.95%）患者被诊断为 PE：91 例左侧和 54 例右侧 PE（19.12%比 11.34%；p=0.001）；双侧受累占 27.19%（31/114 例）。TVS 对右侧 PE 的敏感度为 90.74%（95%CI 79.70-96.92%），左侧为 87.91%（95%CI 79.40-93.81%）。两侧的特异性几乎相同（98.58%比 98.18%）。对于右侧宫旁，阳性似然比（PLR）和阴性似然比（NLR）分别为 63.82（28.70-141.90，95%CI）和 0.09（0.04-0.22，95%CI）。对于左侧宫旁，PLR 和 NLR 分别为 48.35（23.12-101.4，95%CI）和 0.12（0.07-0.21，95%CI）。右侧和左侧 PE 的诊断准确性分别为 97.69%（95.90-98.84%，95%CI）和 96.22%（94.04-97.74%，95%CI）。
主要的局限性是 TVS 高度依赖于操作人员的经验。因此，尽管采用了标准化方法并遵循了精确的解剖学标志定义，但我们不能得出结论认为，所有超声医师观察到的 TVS 对 PE 的准确性是相同的。在这方面，没有评估学习曲线。对于侧方宫旁受累的 TVS 为阴性，术中无可疑病灶的情况下，未行宫旁完全解剖，可能会遗漏较小的 PE 病例，从而低估假阴性。
采用系统方法评估侧方宫旁的 TVS 似乎对 PE 具有良好的诊断准确性，根据 TVS 评估，宫旁受累的后验概率有较大变化。考虑到 PE 的临床和手术意义，建议进一步开展研究，采用标准化方法通过 TVS 评估宫旁，以证实我们的观察结果，并在临床实践中实施标准化方案。
