title: Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in uterosacral ligaments, rectovaginal septum, vagina and bladder: systematic review and meta-analysis.
abstract: OBJECTIVE
  To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of endometriosis in the uterosacral ligaments (USL), rectovaginal septum (RVS), vagina and bladder in patients with clinical suspicion of deep infiltrating endometriosis (DIE).
  
  
  METHODS
  An extensive search was performed in MEDLINE (PubMed) and EMBASE for studies published between January 1989 and December 2014. Studies were considered eligible if they reported on the use of TVS for the preoperative detection of endometriosis in the USL, RVS, vagina and bladder in women with clinical suspicion of DIE using the surgical data as a reference standard. Study quality was assessed using the PRISMA guidelines and QUADAS-2 tool.
  
  
  RESULTS
  Of the 801 citations identified, 11 studies (n = 1583) were considered eligible and were included in the meta-analysis. For detection of endometriosis in the USL, the overall pooled sensitivity and specificity of TVS were 53% (95%CI, 35-70%) and 93% (95%CI, 83-97%), respectively. The pretest probability of USL endometriosis was 54%, which increased to 90% when suspicion of endometriosis was present after TVS examination. For detection of endometriosis in the RVS, the overall pooled sensitivity and specificity were 49% (95%CI, 36-62%) and 98% (95%CI, 95-99%), respectively. The pretest probability of RVS endometriosis was 24%, which increased to 89% when suspicion of endometriosis was present after TVS examination. For detection of vaginal endometriosis, the overall pooled sensitivity and specificity were 58% (95%CI, 40-74%) and 96% (95%CI, 87-99%), respectively. The pretest probability of vaginal endometriosis was 17%, which increased to 76% when suspicion of endometriosis was present after TVS assessment. Substantial heterogeneity was found for sensitivity and specificity for all these locations. For detection of bladder endometriosis, the overall pooled sensitivity and specificity were 62% (95%CI, 40-80%) and 100% (95%CI, 97-100%), respectively. Moderate heterogeneity was found for sensitivity and specificity for bladder endometriosis. The pretest probability of bladder endometriosis was 5%, which increased to 92% when suspicion of endometriosis was present after TVS assessment.
  
  
  CONCLUSIONS
  Overall diagnostic performance of TVS for detecting DIE in uterosacral ligaments, rectovaginal septum, vagina and bladder is fair with high specificity.
authors.affiliation: Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Guerriero
authors.affiliation: Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Ajossa
authors.affiliation: Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.
authors.forename: J A
authors.initials: JA
authors.lastname: Minguez
authors.affiliation: Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Jurado
authors.affiliation: Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy.
authors.forename: V
authors.initials: V
authors.lastname: Mais
authors.affiliation: Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy.
authors.forename: G B
authors.initials: GB
authors.lastname: Melis
authors.affiliation: Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.
authors.forename: J L
authors.initials: JL
authors.lastname: Alcazar
mesh_terms: D004715:Endometriosis / Q000000981:diagnostic imaging* / Q000473:pathology; D005260:Female; D006801:Humans; D008022:Ligaments / Q000000981:diagnostic imaging / Q000473:pathology*; D011237:Predictive Value of Tests; D012007:Rectum / Q000000981:diagnostic imaging / Q000473:pathology*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D018615:Ultrasonography, Doppler, Color; D001745:Urinary Bladder Diseases / Q000000981:diagnostic imaging / Q000473:pathology*; D014621:Vagina / Q000000981:diagnostic imaging / Q000473:pathology*
keywords: bladder endometriosis; deep endometriosis; meta-analysis; rectovaginal septum; systematic review; transvaginal ultrasound; uterosacral ligaments; vaginal endometriosis