[Performance of an Ultrasound Based Endometriosis Staging System (UBESS) for predicting rectal involvement and type of surgical procedure in patients with digestive endometriosis]. / Performance de l'échographie UBESS (Ultrasound Based Endometriosis Staging System) dans la prédiction d'une atteinte rectale et du type de geste opératoire chez les patientes atteintes d'endométriose digestive.

OBJECTIVE: Preoperative assessment of rectal damage in digestive endometriosis requires rectal endoscopic ultra-sonography an invasive exam that is not well received by the patients. A standardized approach using an Ultrasound-Based Endometriosis Staging System (UBESS)could be an interesting tool in this indication. This article aims to evaluate the performance of UBESS in the prediction of rectal involvement and the type of surgical procedure. MATERIALS AND METHODS: This monocentric retrospective study was conducted on patients with rectal endometriosis who underwent a curative surgical procedure, evaluated by UBESS ultrasound between January 2016 and December 2019 at the Poissy referral centre. The main analysis of the study was to assess the adequacy of the UBESS ultrasound stage, the presence of rectal involvement during surgery and the surgical technique required. The secondary objective was to determine the correlation between UBESS stages and RCOG levels of surgical difficulty. RESULTS: A total of one hundred and twenty-two patients were included and one hundred were analysed. Of these, thirty-nine had rectal involvement. There was a statistically significant association between the UBESS stage and the presence of a digestive lesion(P<0.0001). The ultrasound's parameters of thickness(P=0.0007), width(P=0.0082) and volume(P=0.0013) of the digestive lesion were significantly correlated with the extent of the surgical procedure. The correlation between the UBESS and RCOG classifications was very weak. CONCLUSION: UBESS is a powerful diagnostic tool for digestive damage allowing to give clear information to patients before surgery and optimizing the management plan of the surgery.

Early identification of women with endometriosis by means of a simple patient-completed questionnaire screening tool: a diagnostic study.

OBJECTIVES: To assess the value of a self-completed questionnaire based on patients' verbal descriptors of pelvic painful symptoms to identify women with endometriosis. DESIGN: Prospective 1:2 nonmatched case-control study. SETTING: Three French endometriosis referral centers. PATIENT(S): Endometriosis cases were women aged 18-45 years with endometriosis confirmed by histology. Controls were as follows: asymptomatic women attending a gynecologic consultation for routine examination; women without evidence of endometriosis consulting for pain/infertility; and population-based controls from the same urban locations. INTERVENTION(S): All women completed the 21-item yes/no questionnaire about painful symptoms. MAIN OUTCOME MEASURE(S): The area under the receiver operating characteristic curve of the full question set model based on binary logistic regression and the diagnostic accuracy of low- and high-risk classification rules based on selected threshold of the prediction model. RESULT(S): We included 105 cases and 197 controls (45 asymptomatic consultation-based controls, 66 women without endometriosis consulting for pain/infertility, and 86 population-based controls). The full question set prediction model, including age, had an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.87-0.95) after internal validation. The high-risk classification rule had a specificity of 98.0% and a positive likelihood ratio of 30.5. The low-risk classification rule had a sensitivity of 98.1% and a negative likelihood ratio of 0.03. For a hypothesized pretest prevalence of 10%, the high- and low-risk prediction rules ascertained endometriosis with posttest probability rates of 77.2% and 0.3%, respectively. CONCLUSION(S): A self-completed patient-centered questionnaire can identify women at low or high risk of endometriosis with a high diagnostic accuracy and, thus, may help early identification of women with endometriosis.

The ENDOPAIN 4D Questionnaire: A New Validated Tool for Assessing Pain in Endometriosis.

OBJECTIVES: To study the measurement properties, the responsiveness and the minimal clinically important difference of the ENDOPAIN-4D: a new questionnaire for assessing pain in endometriosis. METHODS: A prospective, observational, multicentre study was conducted including all women ≥18 years consulting for symptomatic proven endometriosis between 1 January 2017 and 30 June 2018 and volunteering to participate. Each patient had to answer a new self-administered patient-reported outcome (PRO) questionnaires (the ENDOPAIN-4D) at inclusion (T0) and 12 months after medical or surgical treatment (T1). Criteria defined by COSMIN were used to validate the questionnaire's measurement properties. The minimal clinically important difference was estimated by the anchor-based method. RESULTS: The study included 199 women. The ENDOPAIN-4D score had a four dimensional structure with good internal consistency (measured by Cronbach α): (I) pain-related disability (α = 0.79), (II) painful bowel symptoms (α = 0.80), (III) dyspareunia (α = 0.83), and (IV) painful urinary tract symptoms (α = 0.77). They produced four subscores that can be summed to obtain a single score (α = 0.61). The ENDOPAIN-4D total score ranged from 0 to 94.00 (mean ± SD: 46.7 ± 22). The total score was significantly correlated with the PROs used in endometriosis. Sensitivity to change was good with large effect sizes (ES) (mean of the differences: 36.3 p = 1.8 10-7, ES 0.76). The minimal clinically important difference of the global score was determined to be 10.9. CONCLUSIONS: The ENDOPAIN-4D questionnaire is easy to use, valid, and effective in assessing patient reported pain symptoms in women treated for endometriosis. This new instrument can be used as the primary outcome for future clinical trials and as a tool for routine patient follow-up.

Infertility management according to the Endometriosis Fertility Index in patients operated for endometriosis: What is the optimal time frame?

INTRODUCTION: The Endometriosis Fertility Index (EFI) is a validated score for predicting the postoperative spontaneous pregnancy rate in patients undergoing endometriosis surgery. However, the practical use of the EFI to advise patients about postoperative fertility management is unclear. MATERIALS AND METHODS: All patients participating in the ENDOQUAL study-a prospective observational bi-center cohort study conducted between 01/2012 and 06/2018-who underwent surgery for infertility were asked to complete a questionnaire collecting time and mode of conception. Statistical analysis was performed with the Fine and Gray model of competing risks and analysis of fertility according to the EFI. RESULTS: Of the 234 patients analyzed, 104 (44.4%) conceived postoperatively including 58 (55.8%) spontaneous pregnancies. An EFI of 0-4 for spontaneous pregnancies was associated with a lower cumulative pregnancy incidence compared to an EFI of 5-10 (52 versus 34 pregnancies respectively, Subdistribution Hazard Ratio (SHR) = 0.47; 95% CI [0.2; 1.1]; p = 0.08). An EFI of 0-4 was associated with a higher cumulative pregnancy rate for pregnancies obtained by artificial reproduction technology (ART), compared to an EFI of 5-10 (12 versus 6 pregnancies respectively, SHR = 1.9; CI95% [0.96; 3.8]; p = 0.06). Fecundability decreased from 12 months for EFI 0-4 and from 24 months for EFI 5-10. CONCLUSION: Our analysis suggests that patients with an unfavorable EFI (≤4) have more ART pregnancies than patients with a favorable EFI (≥5) and should be referred for ART shortly after surgery. Patients with a favorable EFI may attempt spontaneous pregnancy for 24 months before referral.

Do high-dose progestins impair sexual function in women treated for endometriosis? A prospective observational longitudinal study.

INTRODUCTION: High-dose progestins are used as an effective therapy for painful symptoms of endometriosis but their impact on sexual function has been poorly studied. The study aims to assess the impact of high-dose progestin on sexual function among women treated for endometriosis. MATERIAL AND METHODS: In this bicenter prospective observational study, women with endometriosis who received medical or surgical treatment for endometriosis and who were sexually active were included. They completed the Sexual Activity Questionnaire (SAQ, a validated tool) before (T0) and 12 months after (T1) endometriosis treatment. We classified patients into two groups according to whether they were using high-dose progestins at T1: a high-dose progestin group and a control group. The main outcome was sexual function measured by the SAQ score (from 0 to 30) at T1. The secondary outcomes were each individual SAQ item, the dyspareunia 100-mm visual analog scale (VAS) and the quality of life assessed with EuroQoL Group 5D Index (EQ-5D) at T1. We also assessed the change in dyspareunia VAS and quality of life between T0 and T1. The Ethics Committee of Ile-de-France (Act 2004-806, 9 August 2004) approved the study. RESULTS: Among 214 women included, 25 (12%) were exposed to high-dose progestins at T1. The SAQ score of women exposed to high-dose progestins was significantly lower compared with the control group, with or without adjustment for covariates (15.5 ± 6.3 vs 18.3 ± 6.2, P = .03, adjusted effect size -0.44 [95% CI -0.86 to -0.02], P = .04). High-dose progestin intake at T1 was associated with a lower subscore on two SAQ items: pleasure (1.8 ± 0.8 vs 2.2 ± 0.9, P = .02), and satisfaction with frequency of intercourse (1.2 ± 1.2 vs 1.8 ± 1.1, P = .02). In the overall population, dyspareunia VAS and quality of life assessed by EQ-5D improved between T0 and T1 (45 ± 29 at T0 vs 28 ± 29 at T1, P < .001; 0.78 ± 0.14 at T0 vs 0.86 ± 0.14 at T1, P < .001, respectively). At T1, the groups did not differ significantly for dyspareunia VAS (effect size 0.36 [95% CI -0.06 to 0.78], P = .10) and quality of life (EQ-5D, effect size 0.02 [95% CI -0.40 to 0.44], P = .91). CONCLUSION: In this observational study, high-dose progestins impair the sexual function of women treated for endometriosis even though they improved dyspareunia.

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes.

STUDY OBJECTIVE: Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity. DESIGN: Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. SETTING: Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. PATIENTS: This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions. INTERVENTIONS: For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves. MEASUREMENTS AND MAIN RESULTS: Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031). CONCLUSION: Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.

Preoperative rectosigmoid endoscopic ultrasonography predicts the need for bowel resection in endometriosis.

BACKGROUND: Rectosigmoid endometriosis is an underdiagnosed disease responsible for abdominal pain, transit disorders and rectal bleeding. Two surgical approaches, rectosigmoid bowel resection (segmental or patch) or intramuscular layer dissection (shaving), are available. AIM: To assess whether the lesion features observed via preoperative rectosigmoid endoscopic ultrasonography (RS-EUS) might predict the need for bowel resection. METHODS: This multicentric retrospective study was conducted on patients with rectosigmoid endometriosis who underwent a curative surgical procedure, evaluated by RS-EUS performed by two trained operators, between January 2012 and March 2018. A univariate statistical analysis was performed on nodules' RS-EUS features (thickness, width, infiltration of the submucosae, presence of a bump into the digestive lumen and presence of multiple rectosigmoid localizations). A multivariate logistic regression was then performed on the significant results. RESULTS: Of the 367 patients, 73 patients with rectosigmoid endometriosis were evaluated by RS-EUS and underwent rectosigmoid surgery. After the univariate analysis was completed, thickness, width and infiltration of the submucosae were identified as potential predictive factors for bowel resection. In a multivariate logistic regression model, only thickness appeared to be a significant [odds ratio (OR) = 1.49, 95% confidence interval (CI): 1.04-2.12, P = 0.028] predictive factor for bowel resection. Receiver operating characteristic analysis performed showed that a thickness over 5.20 mm might be used as cut-off with a sensitivity of 76%, a specificity of 81%, and an area under carve = 0.82. The cut-off values for 100% sensitivity and 100% specificity were 0.90 mm and 10.00 mm, respectively. A trend concerning width to predict the need for resection was also observed (OR 1.12, 95%CI: 1.00-1.26, P = 0.054). CONCLUSION: The presence of a rectosigmoid nodule of endometriosis greater than 5.20 mm thick on RS-EUS might predict the need for bowel resection.