ENDORECT: a preoperative score to accurately predict rectosigmoid involvement in patients with endometriosis.

STUDY QUESTION: Could we construct and validate a preoperative score to predict rectosigmoid involvement in endometriosis (RE)? SUMMARY ANSWER: We developed a simple preoperative score (ENDORECT) to predict RE. WHAT IS KNOWN ALREADY: Accurate preoperative classification is important to optimize the surgical approach for patients with endometriosis but there is currently no reliable first-line examination to determine RE. STUDY DESIGN SIZE DURATION: This was a single-centre observational study including all women (N = 119) who underwent complete surgery for endometriosis between January 2011 and June 2016 in the Gynaecological Department of the University Hospital of Poissy Saint-Germain en Laye. PARTICIPANTS/MATERIALS SETTING METHODS: Of the 119 women, 47 had RE and 72 did not. Two-thirds of the patients were randomly selected to derive the predictive score based on multiple logistic regression with internal validation by bootstrap. We used information from a self-assessment questionnaire, digital and speculum examination, transvaginal ultrasound and MRI. The score was then applied to the remaining sample of patients for validation. MAIN RESULTS AND THE ROLE OF CHANCE: Four variables were independently associated with RE: palpation of a posterior nodule on digital examination (aOR=5.6; 95%CI [1.7-21.8]); a UBESS score of 3 on ultrasonography (aOR=4.9; 95%CI [1.4-19.8); RE infiltration on MRI (aOR=6.8; 95%CI [2-25.5]); and presence of blood in the stools during menstruation (aOR=5.2; 95%CI [1.3-24.7]). The ROC-AUC of the model was 0.86 (95%CI [0.77-0.94]) and the bootstrap procedure showed that the model was stable. The ENDORECT score was derived from these four criteria and three risk groups were identified: the high-risk group (score>17) had a probability of RE of 100% with an specificity (Sp) of 100%, postive likelihood ratio (Lr+)>10; the intermediate-risk group (score: 7-17) had a probability of RE of 42%; and the low-risk group (score=0), with a sensitivity (Se) of 97%, negative likelihood ratio (Lr-) of 0.07 and a probability of RE of 5%. In the validation cohort, a score >17 predicted RE with an Sp of 96, Lr+ of 9.2, and probability of RE of 83%. Patients in this sample with a score=0, had an Se of 100%, Lr- of 0 and a probability of RE of 0%. LIMITATIONS REASONS FOR CAUTION: The single-centre recruitment and over-representation of RE could constitute a referral bias. WIDER IMPLICATIONS OF THE FINDINGS: The use of a preoperative predictive score could facilitate patient counselling and guide surgical management. Both MRI and transvaginal ultrasound provide independent information and are useful before surgery for RE. STUDY FUNDING/COMPETING INTERESTS: No financial support was specifically received for this study. The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Validation of the Sexual Activity Questionnaire in women with endometriosis.

STUDY QUESTION: Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis? SUMMARY ANSWER: For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool. WHAT IS KNOWN ALREADY: Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research. STUDY, DESIGN, SIZE, DURATION: A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population. PARTICPANTS/MATERIALS, SETTINGS, METHODS: Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method). MAIN RESULTS AND THE ROLE OF CHANCE: In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74-0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0-0.6), P = 0.01). The minimally important difference was determined at 2.2. LIMITATIONS, REASONS FOR CAUTION: The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients. WIDER IMPLICATIONS OF THE FINDINGS: The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ. STUDY FUNDING/COMPETING INTEREST(S): This work was funded by the 'Direction à la Recherche Clinique et à l'Innovation' of Versailles, France and the 'Institut de Recherche en Santé de la Femme' (IRSF). The authors have no conflicts of interest to declare.

[Endometriosis: Assessment of the Ultrasound-Based Endometriosis Staging System score (UBESS) in predicting surgical difficulty]. / Endométriose : évaluation du score Ultrasound-Based Endometriosis Staging System (UBESS) dans la prédiction de la difficulté chirurgicale.

OBJECTIVES: Surgical management of endometriosis may require different levels of surgical skill which influences the orientation of the patient. The Ultrasound-Based Endometriosis Staging System (UBESS) is a score developed in 2016 to predict the difficulty of surgery. To study the correlation between UBESS score and two main surgical classifications in the literature. METHODS: Study performed at the center of Poissy, France, between July 2016 and December 2017. Patients who underwent prospective UBESS staging then operated of their endometriosis were included. The patients were classified according to the levels of surgical difficulty of the Royal College of Obstetricians and Gynecologists (RCOG) and the classification created by Chi et al. The criterion of judgment was the correlation between the UBESS stages and RCOG and CHI levels. In a second analysis, we determined the predictive value of the operative plan for items included in the systematic sonographic evaluation described by Menakaya et al. RESULTS: Thirty-three patients were included in the study. Correlation was found to be low between UBESS and RCOG (θ=0.22) and between UBESS and CHI (θ=0.30). The prediction of the operative plan was good for endometrioma, sites specific tenderness, sliding sign, vaginal and digestive tract involvement; but modest for the anterior compartment and uterosacrals ligaments. CONCLUSION: In our study on a small number of patients, the UBESS score does not adequately predict the surgical difficulty. Taken separately, the items of systematic sonographic evaluation based on 5 domains successfully predict the operative plan.