Hum. Reprod. Advance Access originally published online on August 9, 2008
Human Reproduction 2008 23(10):2386-2387; doi:10.1093/humrep/den306
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Letters to the Editor |
Reply: Diagnosis of rectovaginal endometriosis
Department of Obstetrics and Gynaecology, San Martino Hospital, University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
1 Correspondence address. E-mail: dr{at}simoneferrero.com
We thank Abrão et al. for their interest in our study recently published in Human Reproduction (Valenzano Menada et al., 2008
). The primary aim of this study was to evaluate whether RWT-TVS could determine or exclude the presence of rectal endometriotic nodules infiltrating at least the muscular layer of the rectum. In our experience, infiltration of the muscular layer is a critical parameter in determining the type of surgical excision of bowel endometriosis (nodulectomy or bowel resection) (Remorgida et al., 2005). Excluding before surgery, the presence of endometriotic nodules reaching the muscular layer of the rectum is useful for the surgeon in order to obtain adequate consent from the patient and determining whether the assistance of a general surgeon is required (Remorgida et al., 2007).
In their letter, Abrão et al. cited a previous study comparing TVS and magnetic resonance imaging (MRI) in the diagnosis of rectosigmoid endometriosis (Abrão et al., 2007). This study showed that TVS had 98% sensitivity in diagnosing the presence of rectosigmoid endometriosis. Although the authors declared that the various layers of the bowel wall were examined in detail, no data were presented on the accuracy of TVS in determining the depth of infiltration of the endometriotic nodules in the layers of the bowel wall. Abrão et al. cited another study (Bazot et al., 2003) which first showed the usefulness of TVS in diagnosing rectal endometriosis. In this study, TVS correctly diagnosed the infiltration of the muscularis propria in all the cases (n = 18). Unfortunately, we could not reproduce these results and we are not aware of publications of other groups confirming these findings in larger series. In addition, only 30 women were included in the study (Bazot et al., 2003) and 60.0% of them (18/30) had involvement of the bowel muscularis. In our study, surgery revealed that rectal infiltration was present in 29 out of 90 women (32.2%). The prevalence of rectal infiltration in the studied population affects the positive predictive value of TVS; based on this, we believe that the findings of these studies cannot be truthfully compared.
It is well known that the accuracy of ultrasonography is dependent on the experience of the operator. Therefore, RWC-TVS may be useful for ultrasonographers who cannot diagnose the depth of infiltration of the rectal wall by TVS or when more experienced ultrasonographers cannot exclude the infiltration of the rectal muscularis. Obviously, we cannot exclude that some ultrasonographers may avoid the use of this technique for an accurate diagnosis of rectal endometriosis.
Abrão et al. are correct in stating that a simple rectal enema performed 1 h prior to the examination may be sufficient to eliminate the fecal residue in the rectosigmoid colon. Patients included in our study underwent RWC-TVS on the day of surgery after receiving a mechanical bowel preparation which is commonly used at our institute before laparoscopy. This experimental design of our study may be criticized and this limitation of the study design was discussed in the manuscript. We are now evaluating the effectiveness of RWC-TVS in patients who receive only a rectal enema before the exam; our preliminary unpublished observations in this clinical setting confirm the effectiveness of RWC-TVS in determining the presence of endometriotic nodules infiltrating the muscular layer of the rectum.
References
Abrão MS, Gonçalves MO, Dias JA Jr, Podgaec S, Chamie LP, Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod (2007) 22:3092–3097.
Bazot M, Detchev R, Cortez A, Amouyal P, Uzan S, Darai E. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. Hum Reprod (2003) 18:1686–1692.
Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. The involvement of the interstitial Cajal cells and the enteric nervous system in bowel endometriosis. Hum Reprod (2005) 20:264–271.
Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv (2007) 62:461–470.[CrossRef][Web of Science][Medline]
Valenzano Menada M, Remorgida V, Abbamonte LH, Nicoletti A, Ragni N, Ferrero S. Does transvaginal ultrasonography combined with water-contrast in the rectum aid in the diagnosis of rectovaginal endometriosis infiltrating the bowel? Hum Reprod (2008) 23:1069–1075.
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