title: Ultrasound techniques in the diagnosis of deep pelvic endometriosis: algorithm based on a systematic review and meta-analysis.
abstract: OBJECTIVE
  To collate all available evidence with respect to ultrasound techniques in the management of deep pelvic endometriosis (DPE) and compare the sensitivity and specificity of each to determine the most suitable site-specific method. We aim to provide clinicians with information to improve the diagnosis and management of patients with DPE.
  
  
  METHODS
  Systematic review of the literature and meta-analysis.
  
  
  METHODS
  Not applicable.
  
  
  METHODS
  None.
  
  
  METHODS
  Review of MEDLINE, EMBASE, ScienceDirect, Cochrane Library.
  
  
  METHODS
  For each study we calculated the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and positive/negative likelihood ratio regarding DPE sites. We then compared the specificity and sensitivity of each technique. Forest plots with the corresponding 95% confidence interval using fixed/random effects for each approach (both separately and summarized according to the weight of any single study) were used.
  
  
  RESULTS
  A key word search strategy identified 441 manuscripts, 35 of which were eligible for the review (32 for meta-analysis). Standard transvaginal sonography (TVS) showed specificity greater than 85% for all DPE sites, despite sensitivity ranging between 50% (bladder, vaginal wall, and rectovaginal septum) and 84% (rectosigmoid). Modified techniques such as bladder site tenderness-guided TVS showed a value of 97.4% for both sensitivity and specificity. Rectal endoscopy-sonography and rectal water contrast TVS were both superior to TVS in detecting rectosigmoid endometriosis with sensitivities and specificities over 92%. Promising data were reported by using rectal water contrast TVS for rectovaginal septum disease (sensitivity, 97.1%; specificity, 99.3%).
  
  
  CONCLUSIONS
  The summary of data regarding diagnostic specificity and sensitivity of TVS in women undergoing surgery for deep endometriosis may allow us to conclude that TVS should remain the first-line method in the evaluation of patients with suspicion of DPE. When TVS is insufficient, second-line "modified-techniques" should be considered. Choosing the most effective technique is a challenge and should be based on patient history and clinical signs/symptoms.
authors.affiliation: Department of Woman and Child Health, University of Padua, Padua, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Noventa
authors.affiliation: Department of Woman and Child Health, University of Padua, Padua, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Saccardi
authors.affiliation: Department of Woman and Child Health, University of Padua, Padua, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Litta
authors.affiliation: Department of Woman and Child Health, University of Padua, Padua, Italy.
authors.forename: Amerigo
authors.initials: A
authors.lastname: Vitagliano
authors.affiliation: Department of Woman and Child Health, University of Padua, Padua, Italy.
authors.forename: Donato
authors.initials: D
authors.lastname: D'Antona
authors.affiliation: Department of Obstetrics and Gynecology, Northampton General Hospital NHS Trust, Northampton, United Kingdom.
authors.forename: Baydaa
authors.initials: B
authors.lastname: Abdulrahim
authors.affiliation: Department of Obstetrics and Gynecology, Northampton General Hospital NHS Trust, Northampton, United Kingdom.
authors.forename: Alistair
authors.initials: A
authors.lastname: Duncan
authors.affiliation: Department of Obstetrics and Gynecology, Northampton General Hospital NHS Trust, Northampton, United Kingdom.
authors.forename: Farhad
authors.initials: F
authors.lastname: Alexander-Sefre
authors.affiliation: Department of Obstetrics and Gynecology, Northampton General Hospital NHS Trust, Northampton, United Kingdom.
authors.forename: Clive J
authors.initials: CJ
authors.lastname: Aldrich
authors.affiliation: Department of Obstetrics and Gynaecology, University of Verona, Verona, Italy.
authors.forename: Michela
authors.initials: M
authors.lastname: Quaranta
authors.affiliation: Department of Woman and Child Health, University of Padua, Padua, Italy; Department of Obstetrics and Gynecology, Northampton General Hospital NHS Trust, Northampton, United Kingdom. Electronic address: ginecologia_padova@libero.it.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Gizzo
mesh_terms: D000465:Algorithms; D004715:Endometriosis / Q000000981:diagnostic imaging* / Q000601:surgery; D019160:Endosonography / Q000379:methods*; D005260:Female; D006801:Humans; D010388:Pelvis / Q000000981:diagnostic imaging* / Q000601:surgery; D011237:Predictive Value of Tests
keywords: Deep pelvic endometriosis; accuracy; first line approach; patient satisfaction; ultrasound diagnosis