Pre-Treatment Imaging in the Surgical Management of Endometriosis

Background: Preoperative imaging assessment is essential to draw an accurate map of endometriotic lesions. Knowledge of the extension and severity of disease is paramount for the surgical team in order to plan the type of surgery, complete the operating team and properly inform the patient with details of the risks. Material and Method: Transvaginal ultrasound is the first-line imaging technique for ovarian and deep infiltrating endometriosis, but the accuracy of the diagnosis is proportional with the experience of the operator. Respecting the four steps of ultrasound evaluation technique decreases the probability of misdiagnosis. Step 1 include evaluation of the uterus and adnexa, step 2 – evaluation of “soft marker”, step 3 – assessment of the Pouch of Douglas using “sliding sign” and step 4 – assessment of anterior pelvic compartment (urinary bladder, uterovesical region and ureters) and posterior pelvic compartment (rectovaginal septum, posterior vaginal fornix, uterosacral ligaments, rectum and sigmoid). MRI is performed as an additional examination in complex cases prior to surgery, in symptomatic patients with negative or equivocal ultrasound findings and it can be useful for diagnosis of multiple sites of deep infiltrating endometriosis. Results: Important information from recent guidelines and relevant literature are highlighted. Ovarian and deep endometriosis diagnosed by ultrasound scan and MRI imaging – case series (personal experience) will be commented. Conclusion: As with cancer pathology, the success of treatment depends on complete excision of the endometriotic lesions. Rigorous imaging investigation avoids „the tip of the iceberg” mirage and enhances the quality of medical care.