DIAGNOSTIC ACCURACY OF LAPAROSCOPIC VISUAL INSPECTION OF PELVIC ENDOMETRIOSIS

DIAGNOSTIC ACCURACY OF LAPAROSCOPIC VISUAL INSPECTION OF PELVIC ENDOMETRIOSIS

By

Ahmed Mohamed Taha Nasr, Ismail Mohamed Talaat El-Garhy and Khaled Gaber El-Sabaa

Department of Obstetrics and Gynecology, Faculty of Medicine, Al-AzharUniversity

*Corresponding author: Ahmed Mohamed Taha Nasr,

E-mail: dr.ahmed_taha@gmail.com

ABSTRACT

Background: Endometriosis is the presence of endometrial glands or stroma in sites other than reproductive lives. It is associated with symptoms such as pelvic pain, dysmenorrhea, painful sexual intercourse and infertility. Endometriosis can only objectively be confirmed by visualization. This is mainly done by laparoscopy or laparotomy. Laparoscopy allows inspection of the entire pelvis and the extent of disease recorded using a classification system.

Objective: To assess accuracy of visual diagnosis of laparoscopically excised visceral and peritoneal abnormalities suggestive of endometriosis in comparison to histopathological diagnosis.

Patients and methods: This were a cross sectional study for accuracy of a diagnostic test for diagnosis of pelvic endometriosis, conducted on 50 women at laparoscopy unit, Obstetrics and Gynecology Departments Al-Hussein University Maternity Hospital, during the period from July 2019 to October 2021. This study included women planned to undergo diagnostic or operative intervention laparoscopy for pain and/or infertility related to a suggestive diagnosis of pelvic endometriosis.

Results: Pelvic pain was the most frequent clinical presentation with a percentage of 68% as pelvic pain, dyspareunia 46%, dysmenorrhea 38% and infertility 24%. Endometriosis was found in about three quarters of cases of suspected cases. Our results pointed the diagnostic accuracy of visualization by laparoscopy in diagnosis of endometriosis. uterus was the most accurate site (96%), followed by right ovary, left ovary, right ovarian fossa with percentage (92%) each, Douglas pouch and peritoneum (88%) each and left ovarian fossa (86%).

Conclusion: Laparoscopy, particularly a first procedure served both diagnostic and therpeuatic purpose, the intial step was expolaration of pelvis and abdomen. Diagnosis of endometrisos by visual inspection of lesions at laparoscopy was considered satisfactory.

Keywords: Diagnostic accuracy of laparoscopic visual inspection, Pelvic Endometriosis, Histopathological diagnosis

INTRODUCTION

     Endometriosis is a common gynecological disorder affecting at least 11% of reproductive-age women (Buck Louis et al., 2011), but increasing to approximately half of women experiencing pelvic pain or infertility (Giudice, 2010).

     The true incidence and prevalence at the population level remains unknown, in part because of variable clinical diagnostic proficiency (Hsu et al., 2011).

     Endometriosis is difficult to diagnose and is prone to misclassification given its differing symptomatology, paucity of consistent physical examination findings, unpredictable disease course, and lack of an identifying biomarker (Nnoaham et al., 2012).

     Despite the challenges, improving the diagnostic and staging accuracy of endometriosis in women with pelvic pain and infertility is paramount for effectively treating the resulting, sometimes physically or psychologically debilitating conditions (Hsu et al., 2011).

     Furthermore, proper evaluation of potential risk factors or investigational treatments is dependent on consistent diagnosis across clinical centers. Operative real-time laparoscopic findings using standardized staging systems are considered the current gold standard for diagnosing endometriosis and assessing its severity (Practice Committee of the American Society for Reproductive, 2012).

     In accordance with recent guidelines, Dunselman et al. (2014) histopathologic evaluation is recommended for diagnostic confirmation, but its true value had not been adequately quantified because non-standardized and unblended assessment had introduced bias to previous studies. Current advice notes that although positive histology can confirm the diagnosis of endometriosis, negative histology does not exclude it (Dunselman et al., 2014).

     Recording laparoscopic surgeries via digital imaging has become widely accepted among gynaecological surgeons for clinical, research, and medico-legal purposes; however, few studies had assessed the operating surgeon’s findings with those of expert reviewers, particularly among a heterogeneous study population for whom laparoscopies were conducted by a diverse group of surgeons practicing at a variety of clinical centers (Weijenborg et al., 2010).

     The current gold standard for diagnosis of endometriosis is direct visualization of typical or subtle lesions under laparoscopy or laparotomy. Other diagnostic methods, which include serum markers and radiological imaging, are less reliable. There is no reliable test that can be applied to national screening (Jin and Begeurie, 2014).

     The present study aimed to assess accuracy of visual diagnosis of laparoscopically excised visceral and peritoneal abnormalities suggestive of endometriosis in comparison to histopathological diagnosis.

PATIENTS AND METHODS

     This was a cross sectional study for accuracy of a diagnostic test for diagnosis of pelvic endometriosis, conducted on 50 women at laparoscopy unit, Obstetrics and Gynecology, Al-Hussein University Maternity Hospital, during the period from July 2019 to October 2021.

     This study included women planned to undergo diagnostic or operative intervention laparoscopy for pain and/or infertility related to a suggestive diagnosis of pelvic endometriosis.

     The study was designed to assess accuracy of visual diagnosis of laparoscopically excised visceral and peritoneal abnormalities suggestive of endometriosis in comparison to histopathological diagnosis.

     An approval of the study was obtained from Al-AzharUniversity academic and ethical committee. Every patient signed an informed written consent for acceptance of the operation. This work has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans.

Sample size justification: A sample of 50 cases was calculated using epi info program using reliability of visual diagnosis of pelvic endometriosis 75% ±12% and CI 95% (Fernando et al., 2013).

Inclusion criteria: Patients aged 18-40 years undergoing laparoscopy operation for pelvic pain (dyspareunia – dysmenorrhea) and/or infertility causes.

Exclusion criteria: Medical or surgical disorders that contraindicated diagnostic or operative laparoscopy (e.g., respiratory, cardiac….etc.)

All patients were subjected to:

1.   History taking:

a.   Personal history including age and duration of marriage.

b.   Menstrual history and regularity of the menstrual cycle.

c.   Contraception and use of hormonal treatment in the three months previous to the laparoscopy.

d.   History of their infertility and its duration and type (primary or secondary).

e.   Sexual history.

f.    Parity and gravidity.

g.   History of general illnesses (e.g., thyroid disease).

h.   Surgical history.

i.    Past history of systemic diseases such as diabetes mellitus, hypertension, past pre-eclampsia, renal disease, infants with congenital anomalies, and of thyroid troubles.

j.    Family history: diabetes mellitus, hypertension, twins and others.

2.   Examination:

a.   General examination:

•     Height, weight and vital data (blood pressure, pulse, and temperature).

•     The eye for jaundice and edema of the lids.

•     Pallor, cyanosis, hirsutism and pigmentations.

•     The neck for goiter enlarged lymph nodes and congested neck veins.

•     Chest and heart examination.

•     Breast examination for any abnormalities.

•     Limb examination for edema, varicose veins.

•     Back examination for any deformity.

•     The body mass indexes (BMI) of the mothers were derived from weight and height using the usual formula.

•     The BMI was categorized into:

•     Normal (20-24.99).

•     Overweight (25-29.99).

•     Obese (30 and above).

b.   Local gynecological examination (uterine size and mobility, adenexal masses, fullness of posterior fornix… etc.)

3.   Preoperative laparoscopic investigations:

a.   Complete blood picture (CBC).

b.   Liver function test (SGOT, SGPT, ALP, and ALT).

c.   Kidney function test, serum urea and creatinine.

d.   Fasting serum blood sugar.

e.   2 hours post prandial serum blood sugar.

f.    Coagulation profile PT, PTT, INR.

g.   Complete urine analysis.

4.   Pelvic ultrasound.

5.   Hysterosalpingogram as a part of infertility work up.

6.   Laparoscopy postmenstrual (during proliferative phase) for suitable candidates.

     The pelvis and its structures was observed and checked for presence of endometriotic lesions (uterus, tubes, ovaries and ovarian fossae, uterosacral ligaments, Douglas pouch, uterovesical pouch, broad ligaments and lateral pelvic walls).

     Endometriosis positive patients was then classified to stages I-IV according to the American Fertility Society scoring system for endometriosis.

Statistical Methods:

     The collected data were coded, processed and analyzed using the SPSS (Statistical Package for the Social Sciences) version 22 for Windows® (IBM SPSS Inc, Chicago, IL, USA). Qualitative data were represented as frequencies and relative percentages. Quantitative data were expressed as mean ± SD (Standard deviation).

ROC-curve: Receiver Operating Characteristic curve analysis was used to calculated sensitivity, specificity, PPV and NPV (positive and negative protective values) and accuracy.

RESULTS

     Pelvic pain was the most frequent clinical presentation. Grade I was the most frequent frade (Table 1).

Table (1):   Demographic charactersitcs, clinical presentation and grades of suspected endometriosis by laparoscopy of the studied cases (N=50)

     Douglas pouch and peritoneum were the most frequent sites, while uterus was the least frequent site (Table 2).

Table (2):   Endometriosis by laparoscopy and histopathology in different sites (N=50)

     There was a significant moderate agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in uterus (Table 3).

Table (3):   Agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in uterus

Percentages were from the total (100), TP: True positive, TN: Truenegative, FP: False positive, FN: Falsenegative, CI: Confidence interval

     There was a significant moderate agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in Douglas pouch (Table 4).

Table (4):   Agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in Douglas pouch

Percentages are from the total (100), TP: True positive, TN: Truenegative, FP: False positive, FN: Falsenegative, CI: Confidence interval

     There was a significant moderate agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in peritoneum (Table 5).

Table (5):   Agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in peritoneum

Percentages were from the total (100), TP: True positive, TN: Truenegative, FP: False positive, FN: Falsenegative, CI: Confidence interval

     Findings of false-suspected left ovary and right ovarian fossa endometriosis by laparoscopy showed equal percentages of non-specific inflammation and no abnormality (50%) each. Findings of false-suspected left ovarian fossa endometriosis by laparoscopy showed (40%) non-specific inflammation and (60%) no abnormality. Findings of false-suspected douglas pouch and peritoneum endometriosis by laparoscopy showed (66.7%) non-specific inflammation and (33.3%) no abnormality (Table 6).

Table (6):   Histopathology finding of false-suspected endometriosis by laparoscopy

DISCUSSION

     Results of the present study showed that, pelvic pain was the most frequent clinical presentation with a percentage of 68% of pelvic pain, dyspareunia 46%, dysmenorrhea 38% and infertility 24%. Endometriosis was found in about three quarters of cases of suspected cases. Bulletti et al., (2010) found that the most common symptoms of endometriosis were dysmenorrhea 60-80%, pelvic pain and dyspareunia 40-50%, infertility 30-50%. Salehpour et al. (2010) showed that patients presented with a primary complaint of chronic pelvic pain (13.3%) dysmenorrhea (40%), primary infertility (70%) and secondary infertility (26%). Fassbender et al. (2013) study laparoscopy revealed endometriosis in 40% (21/53) of cases. In endometriosis cases, most frequent symptoms described by patients were dysmenorrhea and dyspareunia followed by vibration pain, urinary symptoms and lowered fertility.

     In our study, studying the grades of suspected endometriosis by laparoscopy revealed that, grade one was the most frequent grade 33.3%, followed by grade four 26.2%, grade three 23.8% and grade two 16.7%. de Almeida Filho et al. (2015) showed that 45.9% were classified presenting endometriosis grades I and II, and 336 patients (54.1%) with grades III and IV. Fassbender et al. (2013) found in all cases the stage of the endometriosis was grade I (N = 15) or grade II, which indicated minimal disease. Mettler et al. (2012) found that the majority of patients, (59.8%), had stage I endometriosis, (8.5%) had stage II, (17%) stage III, and (14.6%) stage IV endometriosis. The majority of patients, (67.7%), were found to have multiple lesions, and (32.3%) had single lesions.

     It is obvious from our results that Douglas pouch and peritoneum were the most frequent sites (20%) for each, while uterus was the least frequent site represented 8% among studied cases when studying endometriosis by laparoscopy and histopathology. Schrager et al. (2013) correlated the diagnosis of endometriosis on the basis of visualization at laparoscopy with the pathologic diagnosis in a prospective study the mean prevalence of abnormalities visually consistent with endometriosis was 36%, with 18% confirmed histologically. The positive predictive value was 45%; sensitivity, 97%; negative predictive value, 99%; and specificity, 77%; for visual versus histologic diagnosis of endometriosis. Thirty-six percent of the diagnoses were downstage on the basis of histologic findings. Sourial et al. (2014) reported the clinical characteristics of adolescent patients with endometriosis monitored in a tertiary hospital. The age ranged from 17.95 ± 1.48 years, the sites affected were ovarian (38%), peritoneal (47.6%) and retrocervical (23.8%). Dysmenorrhea was found in 80.9 % of adolescents (severe in 33.3% of cases) and chronic pelvic pain in 66.6%. Mettler et al. (2014) determined the prevalence of endometriosis among women with proven fertility in Santiago de Chile. Endometriosis was found in 14 of the 287 women (4.9%). In spite of being asymptomatic, five of the 14 women with endometriosis were classified as severe, due to the presence of at least one endometrioma. In order of frequency, the most commonly affected anatomical sites were the ovary, the peritoneum, the posterior cul-de-sac and uterosacral ligaments.

     Regarding agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in uterus, there was a significant moderate agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in uterus. Our study showed significant moderate agreement between laparoscopy visualization and histopathology in diagnosis of endometriosis in left ovary, right ovarian fossa, left ovarian fossa, Douglas pouch and peritoneum. Mehedintu et al. (2014) determined the correlation between visual and histologic findings of endometriosis at laparoscopy. Laparoscopy was confirmed to be in 100% diagnostic accordance with pathology for patients with endometriosis. 80.3% of ovarian endometriotic cysts diagnosed by laparoscopy were confirmed histologically with 43.6% in the left, 27.3% in the right; and 29.1% in both sides of the ovary. In addition, 18.5% of normal-appearing peritoneal biopsy were identified as endometriosis by pathological examination. According to Acien et al. (2012), laparoscopic visualization of endometriosis does not always correlate with histopathologic diagnosis; several other lesions may mimic endometriosis on histopathologic examination.

     Our results pointed the diagnostic accuracy of visualization by laparoscopy in diagnosis of endometriosis, uterus was the most accurate site (96%), followed by right ovary, left ovary, right ovarian fossa with percentage (92%) each, douglas pouch and peritoneum (88%) each and left ovarian fossa (86%). Mettler et al. (2012) analyzed the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 100%. The ovarian fossa, confirmed in 66.7%, and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 60.1%. As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesico uterine fold of the peritoneum were 48%, 40%, and 13%, respectively.

     This study revealed the histopathology findings of false-suspected endometriosis by laparoscopy: Findings of false-suspected left ovary and right ovarian fossa endometriosis by laparoscopy showed equal percentages of non-specific inflammation and no abnormality (50%) each. Findings of false-suspected left ovarian fossa endometriosis by laparoscopy showed (40%) non-specific inflammation and (60%) no abnormality. Findings of false-suspected douglas pouch and peritoneum endometriosis by laparoscopy showed (66.7%) non-specific inflammation and (33.3%) no abnormality.

     In the study of Florio et al. (2011) in patients who underwent laparoscopy, 33% did not exhibit any signs of endometriotic disease during laparoscopic inspection of the pelvis. 60% did not reveal any pelvic abnormalities, whereas 11% observed macroscopically the features consistent with chronic pelvic inflammatory disease. Dense pelvic adhesions were observed 29%.

In the study of de Almeida Filho et al. (2015), by taking the histopathological findings to be definitive for the diagnosis of endometriosis, the clinical suspicion and laparoscopic findings presented 97.68% sensitivity, 79.23% specificity, 72% positive predictive value, 98.42% negative predictive value, and 85.75% accuracy. False positive results were obtained in 27.99% of the tests, compared with false negative results in 1.57% of the tests.

     In the study of Moini et al. (2012) at histopathology, the diagnosis of deep endometriosis was confirmed in 82/115 (71.3%) patients. The highest accuracy was for adenomyosis (100%) and endometriosis of utero-sacral ligaments (USLs) (98%), slightly lower for vagina-rectovaginal septum a colo-rectal walls (96%), and the lowest for bladder endometriosis (92%).

CONCLUSION

     Laparoscopy, particularly a first procedure served both diagnostic and therpeuatic purpose, the intial step was expolaration of pelvis and abdomen. Diagnosis of endometrisos by visual inspection of lesions at laparoscopy was considered satisfactory.

REFERENCES

1. Acien P, Bataller A, Fernandez F, Acien MI, Rodriguez JM and Mayol MJ. (2012): New cases of accessory and cavitated uterine masses (ACUM): a significant cause of severe dysmenorrheal and recurrent pelvic pain in young women. Human Reproduction, 27(3): 683–694.
2. Buck Louis GM, Hediger ML, Peterson CM, Croughan M, Sundaram R and Stanford J. (2011): Incidence of endometriosis by study population and diagnostic method: The ENDO study. Environ Health Perspect, 96:360–5.
3. Bulletti C, Coccia ME, Battistoni S and Borini A. (2010): Endometriosis and infertility. J Assist Reprod Genet., 27:441–447.
4. de Almeida Filho DB, de Oliveira LJ and do Amaral VF. (2015): Accuracy of laparoscopy for assessing patients with endometriosis. Sao Paulo Med J., 126(6):305-8.
5. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T and De Bie B. (2014): ESHRE guideline: management of women with endometriosis. Hum Reprod., 29:400–12.
6. Fassbender A, Vodolazkaia A and Saunders P. (2013): Biomarkers of endometriosis. Fertility and Sterility, 99(4):1135–1145.
7. Fernando S, Soh PQ, Cooper M, Evans S, Reid G, Tsaltas J and Rombauts L. (2013): Reliability of visual diagnosis of endometriosis. J Minim Invasive Gynecol., 20:783–789.
8. Florio P, Reis FM and Torres PB. (2011): High serum follistatin levels in women with ovarian endometriosis. Human Reproduction, 24(10):2600–2606.
9. Giudice LC. (2010): Clinical practice. Endometriosis. N Engl J Med., 362:2389–98.

10. Hsu AL, Sinaii N, Segars J, Nieman LK and Stratton P. (2011): Relating pelvic pain location to surgical findings of endometriosis. Obstet Gynecol., 118:223–30.

11. Jin X and Begeurie JR. (2014): Laparoscopic surgery for subfertility related to endometriosis: A meta-analysis. Taiwanese Journal of Obstetrics & Gynecology, 53: 303-308.

12. Mehedintu C, Plotogea MN, Ionescu S and Antonovici M. (2014): Endometriosis still a challenge. Journal of Medicine and Life, 7(3):349-357.

13. Mettler L, Ruprai R and Alkatout I. (2014): Impact of Medical and Surgical Treatment of Endometriosis on the Cure of Endometriosis and Pain. Bio Med Research International, 14: 264-269.

14. Mettler L, Schollmeyer T and Alkatout I. (2012): Adhesions during and after surgical procedures, their prevention and impact on women's health. Women’s Health, 8(5): 495–498.

15. Moini A, Bahar L, Ashrafinia M, Eslami B, Hosseini R and Ashrafinia N. (2012): Fertility Outcome after Operative Laparoscopy versus No Treatment in Infertile Women with Minimal or Mild Endometriosis. International Journal of Fertility and Sterility, 5(4): 235-240.

16. Nnoaham KE, Webster P, Kumbang J, Kennedy SH and Zondervan KT. (2012): Is early age at menarche a risk factor for endometriosis? A systematic review and meta-analysis of case-control studies. Fertil Steril., 98:702–712.

17. Practice Committee of the American Society for Reproductive Medicine. (2012): Endometriosis and infertility: a committee opinion. Fertil Steril., 98:591–8.

18. Salehpour S, Zhaam H, Hakimifard M, Khalili L and Gashb YA. (2010): Evaluation of Diagnostic Visual Findings at Laparoscopy in Endometriosis. Iranian Journal of Fertility and Sterility, 1(3): 123-126.

19. Schrager S, Falleroni J and Edgoose J. (2013): Evaluation and Treatment of Endometriosis. American Family Physician, 87(2):108-113.

20. Sourial S, Tempest N and Hapangama DK. (2014): Theories on the Pathogenesis of Endometriosis. International Journal of Reproductive Medicine, 14: 179-183.

21. Weijenborg PT, ter Kuile MM and Jansen FW. (2010): Intra observer and inter observer reliability of videotaped laparoscopy evaluations for endometriosis and adhesions. Fertil Steril., 87:373–80.