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The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis



Comparison of preoperative magnetic resonance imaging (MRI) with intraoperative findings in patients with deep infiltrating endometriosis (DIE) by means of the ENZIAN score.


This retrospective two-center study includes 63 patients with deep infiltrating endometriosis, who underwent surgery between 2012 and 2016 at both the University Hospital of Zurich and the Cantonal Hospital of Schaffhausen. Inclusion criteria were a preoperative pelvic MRI and intraoperative or bioptic confirmation of DIE. The preoperative MRI findings were compared with the intraoperative results by means of the ENZIAN score. Furthermore, the various MRI sequences were analyzed for their diagnostic value based on a Likert scale.


Sensitivity and negative predictive values of MRI confirmed by surgery were 95.2% and 91.7% (lesions in the vaginal/rectovaginal space), 78.4% and 56% (uterosacral ligaments), 91.4% and 89.7% (rectum/sigmoid colon), 57.1% and 94.1% (myometrium), 85.7% and 98.3% (bladder), and 73.3% and 92.2% (intestine), respectively. T2 axial and sagittal MRI sequences in combination with a T1 sequence were diagnostically sufficient.


The MRI-based ENZIAN score correlates well with the intraoperative findings, enabling a better planning of the surgical procedure for patients and physicians. However, considerable difficulty and a poorer comparability result from the variations in sequences used in the detection of this multifaceted disease. Therefore, a standardization of MRI protocols used in the detection of DIE will be a crucial step towards increased diagnostic validity and the ENZIAN score may be used as an anatomical land map and valuable communication tool between radiologists and gynecologists.

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The authors thank Burkhardt Seifert for statistical consulting.

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Correspondence to Laurin Burla.

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The author Laurin Burla declares that he has no conflict of interest. The author David Scheiner declares that he has no conflict of interest. The author Eleftherios Pierre Samartzis declares that he has no conflict of interest. The author Stefan Seidel declares that he has no conflict of interest. The author Markus Eberhard declares that he has no conflict of interest. The author Daniel Fink declares that he has no conflict of interest. The author Andreas Boss declares that he has no conflict of interest. The author Patrick Imesch declares that he has no conflict of interest.

Ethical approval

All the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved prior to its initiation by the cantonal ethics committee of Zurich (2016–00613).

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Informed consent was obtained from all individual participants included in the study.

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Burla, L., Scheiner, D., Samartzis, E.P. et al. The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis. Arch Gynecol Obstet 300, 109–116 (2019).

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  • Preoperative planning in deep infiltrating endometriosis
  • Deep infiltrating endometriosis
  • ENZIAN score
  • MRI
  • Endometriosis