1. Ultrasound Based Staging System As A Triage Tool For Laparoscopic Treatment Of Endometriosis Menakaya U, Reid S, Lu C, Condous G Fellow and Clinical Associate Lecturer Acute Gynaecology, Early Pregnancy and Advanced Endoscopic Unit Nepean Hospital and University of Sydney Medical School Kingswood, Penrith

2. Background WES recommendation - Centers of expertise for management of higher stage endometriosis. Recommendation requires a triaging system Current triaging systems are intraoperative Associated with high health costs and surgical risks for patients

3. Objectives To develop a practical pre-operative ultrasound based staging system to predict severity of endometriosis 1.Correlate ultrasound prediction of components of staging system with gold standard laparoscopy 2. Utilize staging system to triage women to appropriate surgical expertise.

4. Materials & Methods Multicentre prospective observational study January 2009 to February 2013 Setting: endometriosis referral centre, university hospital, private sites Patients: 200 women, reproductive age, history of chronic pelvic pain or endometriosis Women included had complete ultrasound and laparoscopy data

5. Ultrasound data –Same systematic approach inclusive of all phenotypes of endometriosis (peritoneal disease, adhesions, DIE, endometriomata) –Same advanced gynaecology sonologists Pre-operative ultrasound staging system (I – IV) –developed retrospectively –Grouped together specific pelvic features on TVS –Associated with endometriosis Assignment of AGES laparoscopic skill level (I – VI) –Operative findings recorded in database –Different laparoscopic surgeons involved –Skill levels assigned. Materials & Methods

6. DomainTVS Technique Endometriosis Phenotype 1Routine assessment of uterus and adnexa Uterine version Adenomyosis Ovarian endometriosis Domain Based TVS Approach To Evaluation Of Pelvis In Endometriosis DomainTVS TechniqueEndometriosis Phenotype 2Soft markers for endometriosis Possible peritoneal disease Ovarian adhesions DomainTVS TechniqueEndometriosis Phenotype 3Real time dynamic “sliding sign” POD obliteration DomainTVS TechniqueEndometriosis Phenotype 4Office Gel Sonovaginography Non bowel Posterior compartment DIE 5Assessment of anterior wall of large bowel Bowel DIE “The Endometriosis Scan”

7. EndometriomaBowel and Non bowel DIE Peritoneal disease Endometriosis Phenotypes Adhesions

8. ULTRASOUND MARKERACCURACY %SENSITIVITY % Endometrioma Left Right Bilateral 80.4 82.4 86 77.1 66 63.2 Deep Infiltrating Endometriosis (total)87.978.5 Midline posterior compartment8983.3 Lateral posterior compartment91.523.5 POD obliteration9690.2 Performance Of Specific TVS Markers Vs. gold standard laparoscopy RESULTS

9. STAGES Stage 1 Stage 2 Stage 3 Stage 4 FEATURES ASSESSED ON TRANSVAGINAL ULTRASOUND Soft marker –site specific tenderness in POD with mobile ovaries Endometrioma - absent POD – Positive sliding sign DIE nodules – Absent Soft marker – site specific tenderness in POD with/without mobile ovaries Endometrioma - Present POD – Positive sliding sign DIE nodules – Absent Soft marker – site specific tenderness in POD with/without mobile ovaries Endometrioma – present or absent POD – Positive sliding sign DIE nodules – Present Soft marker – site specific tenderness in POD with/without Mobile ovaries Endometrioma – present or absent POD – Negative sliding sign DIE nodules – Present PREDICTED FINDINGS AT LAPAROSCOPY Possible peritoneal disease alone Ovarian endometriosis +/- Peritoneal disease Normal POD DIE nodules absent Peritoneal disease +/- ovarian endometriosis Normal POD DIE nodules present Peritoneal disease +/- ovarian endometriosis Obliterated POD DIE nodules present AGES LAPAROSCOPIC SKILL LEVEL Level 1 - 2 Level 3 Level 4 Ultrasound stage I – IV, Predicted laparoscopic findings and AGES skill level I - VI Level 6

10. TVS StageSurgical Skill Level Level 1-2Level 3Level 4Level 6 Stage 181331 Stage 2162131 Stage 34074 Stage 412046 80.3% accurate prediction of exact laparoscopic skills required. Correlating ultrasound stages (I-IV) and AGE laparoscopic skill levels (I – VI)

11. DISCUSSION Practical, simple and comprehensive preoperative staging system for endometriosis. Key differences with other staging system. –Preoperative –Woman centred –Inclusive of all phenotypes –Spectrum of hard markers Criticisms –Retrospective staging –Stage 3: DIE locations require different lap skill sets –Poor performance - Stage 2 and 3 – learning curve required.

12. CONCLUSION Potential role in preoperative triage of patients with higher stage disease. For General practitioners - Engender appropriate referral For Generalists - Appreciation of severity of disease For AGES advanced - Preoperative counseling laparoscopists Surgical list planning, Multidisciplinary team involvement (colorectal, urology etc. ) Large-scale multi center prospective studies are needed to validate this staging system

13. Thank you

14. AGES LAPAROSCOPIC SKILL LEVELS AS RELATES TO ENDOMETRIOSIS Skill level 1Diagnostic laparoscopy. Skill Level 2 Simple adhesiolysis, ablation of minor stage endometriosis (AFS I-II). Skill level 3 Laparoscopic Cystectomy/oophorectomy when there is normal anatomy. Skill level 4Excisional surgery for AFS III Skill level 6Distorted anatomy, excision of endometriotic nodules. Pls note: level 5 refers to LAVH and myomectomy and does not relate to endometriosis.

15. Performance Of Specific TVS Markers Vs. gold standard laparoscopy Endometrioma alone: 32% Inclusion of domain 3 and 5: 82%

16. AGES LAPAROSCOPIC SKILL LEVEL ACCURACYSENSITIVITYSPECIFICITYPPVNPV 1-285.1%79%92.3%92%80% 387%80.7%88.1%51.2%96.7% 492.7%54%95.6%46.6%96.6% 695.3%88.5%97.8%93.9%95.9% Predicting Appropriate Skill Level using staging system

17. OVARIAN IMMOBILITY ACCURACY % SENSITIVITY % P VALUE Left ovary80.477.13.6E-13 Right ovary82.4668.2E-13 Both ovaries86.063.24.4E-12 Site specific tenderness Vs. Location Of Peritoneal Endometriosis Ovarian Immobility: TVS Prediction Vs. gold standard Laparoscopy Soft markers vs. gold standard laparoscopy P<0.05 RESULTS

18. Endometrioma vs. gold standard laparoscopy RESULTS PREVALENCEACCURACYSENSITIVITYP VALUE L. Ovary19.1%95%86.8%4.3E-27 R. Ovary17.1%90.5%61.8%1.4E-14 Both ovaries 9%96.0%72.2%5.4E-14

19. POD Obliteration vs. gold standard laparoscopy POD OBLITERATION AT GEL SVGAT SURGERY YesNo Yes202 No077 POD OBLITERATION AT GEL SVGAT SURGERY YesNo Yes261 No568 FIRST 100 CASES Accuracy : 0.94 Sensitivity : 0.839 LATEST 100 CASES Accuracy : 0.980 Sensitivity: 1.0 OVERALL ACCURACY AND SENSITIVITY 96% AND 90.2%

20. Deep Infiltrating Endometriosis: Bowel and non bowel vs. gold standard laparoscopy LOCATION OF LESIONS at LAPAROSCOPY PREVALENCE (%) ACCURACY (%) SENSITIVITY (%) TOTAL – DIE32.787.9%78.5% TOTAL - BOWEL2489.0%83.3% RECTOCERVICAL19%90.5%71.1% RECTOCERVICAL + SIGMOID23.5%88.0%61.7% UTEROSACRAL8.591.5%23.5% VAGINAL595.5%20.0% RECTOVAGINAL SEPTUM4.596.5%22.2% RECTOVAGINAL SEPTUM + VAGINAL793.5%14.3% RETRORECTAL0.5%93.5%0.0%

21. PHENOTYPES OF ENDOMETRIOSIS Peritoneal endometriosis Ovarian adhesions Posterior compartment adhesions (POD obliteration) DIE nodules (Bowel and non bowel) Ovarian endometrioma Endometriosis phenotypes, ultrasound findings and gold standard laparoscopy

22. AFS classifications - shortcomings Arbitrary point scores unsupported by data. Features of infertility were emphasized but not the features necessarily related to pelvic pain Potential for observation bias Limited reproducibility Failure to consider lesion morphologic type No correlation between severity of endometriosis with pregnancy rates after surgery

23. Endometriosis: Historical perspectives Pre AFSPre 1973Post 1973AFSPost AFSTVS