Skip to main content
SpringerLink
Log in

Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis

  • General Gynecology
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

The aim of this study is to investigate the correlation between the magnetic resonance imaging (MRI) and intraoperative findings of deep infiltrating endometriosis using the #ENZIAN score.

Methods

This retrospective study included 64 patients who underwent surgery for deep infiltrating endometriosis between January 2017 and August 2020. Preoperative abdominopelvic MRI assessment was evaluated and scored using the #ENZIAN classification. Operative scores were considered the gold standard, and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of MRI for each category were calculated.

Results

MRI has higher sensitivity and specificity in showing the lesions of the compartments O (ovarian lesions), A (rectovaginal septum and posterior vaginal fornix), and B (uterosacral ligaments and parametrium) (100–100%, 100–100%, and 97–100%, respectively, p < 0.001) compared to the other compartments. The lowest sensitivity, specificity, accuracy, and PPV of the MRI was found in compartment P (14%, 76%, 70%, and 7%, respectively).

Conclusion

We demonstrated that the #ENZIAN classification in MRI reports has significant sensitivity and specificity in compartments A, B (uterosacral ligaments and parametrium), and O. Furthermore, the determination of peritoneal lesions via MRI is inadequate.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Foti PV, Farina R, Palmucci S, Vizzini IAA, Libertini N, Coronella M, Spadola S, Caltabiano R, Iraci M, Basile A, Milone P, Cianci A, Ettorre GC (2018) Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights Imaging 9(2):149–172

    Article  Google Scholar 

  2. Chamié LP, Blasbalg R, Pereira RM, Warmbrand G, Serafini PC (2011) Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics 31(4):E77-100

    Article  Google Scholar 

  3. Ballard K, Lowton K, Wright J (2006) What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of endometriosis. Fertil Steril 86:1296–1301 (PubMed: 17070183)

    Article  Google Scholar 

  4. Hadfield R, Mardon H, Barlow D, Kennedy S (1996) Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. Hum Reprod 11:878–880 (PubMed: 8671344)

    Article  CAS  Google Scholar 

  5. Nnoaham KE, Hummelshoj L, Webster P, d’Hooghe T, de Cicco NF, de Cicco NC, Jenkinson C, Kennedy SH, Zondervan KT (2011) World Endometriosis Research Foundation Global Study of Women’s Health consortium. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 96(2):366–3738

    Article  Google Scholar 

  6. Medeiros LR, Rosa MI, Silva BR, Reis ME, Simon CS, Dondossola ER, da Cunha Filho JS (2015) Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet 291(3):611–621

    Article  Google Scholar 

  7. Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, Bush D, Kiesel L, Tamimi R, Sharpe-Timms KL, Rombauts L, Giudice LC (2017) World Endometriosis Society Sao Paulo Consortium. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 32(2):315–324

    Article  Google Scholar 

  8. Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, Krentel H, Janschek E, Exacoustos C, Malzoni M, Mueller M, Roman H, Condous G, Forman A, Jansen FW, Bokor A, Simedrea V, Hudelist G (2021) The #Enzian classification: a comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 100(7):1165–1175

    Article  Google Scholar 

  9. Bazot M, Bharwani N, Huchon C, Kinkel K, Cunha TM, Guerra A et al (2017) European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 27(7):2765–2775. https://doi.org/10.1007/s00330-016-4673-z (Epub2016/12/05, PubMedPMID:27921160;PubMedCentralPMCID:PMCPMC5486785)

    Article  CAS  Google Scholar 

  10. Burla L, Scheiner D, Samartzis EP, Seidel S, Eberhard M, Fink D, Boss A, Imesch P (2019) The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis. Arch Gynecol Obstet 300(1):109–116

    Article  Google Scholar 

  11. Burla L, Scheiner D, Hötker AM, Meier A, Fink D, Boss A, Imesch P (2021) Structured manual for MRI assessment of deep infiltrating endometriosis using the ENZIAN classification. Arch Gynecol Obstet 303(3):751–757

    Article  Google Scholar 

  12. Di Paola V, Manfredi R, Castelli F, Negrelli R, Mehrabi S, Pozzi Mucelli R (2015) Detection and localization of deep endometriosis by means of MRI and correlation with the ENZIAN score. Eur J Radiol 84(4):568–574

    Article  Google Scholar 

  13. Ruffo G, Sartori A, Crippa S et al (2012) Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results. Surg Endosc 26:1035–1040

    Article  Google Scholar 

  14. Maytham GD, Dowson HM, Levy B et al (2010) Laparoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature. Colorectal Dis 12:1105–1112

    Article  CAS  Google Scholar 

  15. Koh CE, Juszczyk K, Cooper MJ et al (2012) Management of deeply infiltrating endometriosis involving the rectum. Dis Colon Rectum 55:925–931

    Article  Google Scholar 

  16. Tomassetti C, Meuleman C, Vanacker B et al (2009) Lower limb compartment syndrome as a complication of laparoscopic laser surgery for severe endometriosis. Fertil Steril 92:2.038E12-2.038E15

    Article  Google Scholar 

  17. Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2(2):CD009591

    Google Scholar 

  18. Andres MP, Borrelli GM, Abrão MS (2018) Endometriosis classification according to pain symptoms: can the ASRM classification be improved? Best Pract Res Clin Obstet Gynaecol 51:111–118

    Article  Google Scholar 

  19. Canis M, Donnez JG, Guzick DS, Halme JK, Rock JA, Schenken RS, Vernon MW (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67(5):817–821

    Article  Google Scholar 

  20. Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F, Crosignani PG (1996) Endometriosis and pelvic pain: relation to disease stage and localization. Fertil Steril 65(2):299–304

    Article  CAS  Google Scholar 

  21. Vercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, Crosignani PG (2006) Reproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system. Hum Reprod 21(10):2679–2685

    Article  Google Scholar 

  22. Guzick DS, Silliman NP, Adamson GD, Buttram VC, Canis M, Malinak LR et al (1997) Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine’s revised classification of endometriosis. Fertil Steril 67(5):822–829

    Article  CAS  Google Scholar 

  23. Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG (2007) Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients. Hum Reprod 22(1):266–271

    Article  CAS  Google Scholar 

  24. Haas D, Oppelt P, Shebl O, Shamiyeh A, Schimetta W, Mayer R (2013) Enzian classification: does it correlate with clinical symptoms and the rASRM score? Acta Obstet Gynecol Scand 92:562–566

    Article  Google Scholar 

  25. Mutuku T (2016) Prä-operative Abschätzung einer tief infiltrierenden Darmendometriose mittels Untersuchungsbefund in der ENZIAN-Klassifikation und der Symptomatik sowie Vergleich mit dem intra- operativen ENZIAN-Befund [The assessment of deep infiltrating endometriosis according to the preoperative investigation and symptoms in comparison to intraoperative findings with the ENZIAN- Classification]. MD Thesis, Universität Ulm. https://doi.org/10.18725/OPARU-3751

  26. Haas D, Chvatal R, Habelsberger A et al (2013) Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification. Eur J Obstet Gynecol Reprod Biol 166:99–103

    Article  Google Scholar 

  27. Roman H, Moatassim-Drissa S, Marty N et al (2016) Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril 106:1438–45.e2

    Article  Google Scholar 

  28. Alves J, Puga M, Fernandes R, Pinton A, Miranda I, Kovoor E, Wattiez A (2017) Laparoscopic management of ureteral endometriosis and hydronephrosis associated with endometriosis. J Minim Invasive Gynecol 24(3):466–472

    Article  Google Scholar 

  29. Kiesel L, Sourouni M (2019) Diagnosis of endometriosis in the 21st century. Climacteric 22(3):296–302

    Article  CAS  Google Scholar 

  30. Novellas S, Chassang M, Delotte J, Toullalan O, Chevallier A, Bouaziz J, Chevallier P (2011) MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. AJR Am J Roentgenol 196:1206–1213. https://doi.org/10.2214/AJR.10.4877

    Article  Google Scholar 

Download references

Funding

The authors have not disclosed any funding.

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Zuhuratbaba Mh. Tevfik Saglam Cd. No: 11 Bakirkoy, Istanbul, Turkey

    Aysun Fendal Tunca & Derya Ece Iliman

  2. Department of Radiology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey

    Aysegul Akdogan Gemici

  3. Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University, Acibadem Bakirkoy Hospital, Istanbul, Turkey

    Cihan Kaya

Authors
  1. Aysun Fendal Tunca
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Derya Ece Iliman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Aysegul Akdogan Gemici
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cihan Kaya
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AFT contributed to concept, study design and manuscript writing. DEI contributed to data collecting and manuscript writing, AAG evaluate the MRI and collected the data, and CK contributed to concept, study design. Data analysing and manuscript editing. All authors read and approved the submitted manuscript.

Corresponding author

Correspondence to Aysun Fendal Tunca.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fendal Tunca, A., Iliman, D.E., Akdogan Gemici, A. et al. Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis. Arch Gynecol Obstet 307, 215–220 (2023). https://doi.org/10.1007/s00404-022-06451-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00404-022-06451-1

Keywords

Search

Navigation